Who Qualifies? A Medicare patient with any of the conditions listed in step #2 on the right could be eligible for Therapeutic Shoes. Ask Your Doctor !!!

What is Covered? Medicare will cover 80% of the allowed amount for:

* One pair of extra depth shoes * Three pairs of inserts per Year

Secondary Insurance may cover the remaining 20%

What To Do Now? Follow these simple directions to receive your Therapeutic Footwear:

Step 1: See your doctor to have the prescription form to the right filled out.

Step 2: Call The Prescription Shop @ 251-1620 to schedule an appt.

Step 3: We will verify your Medicare & Insurance coverage and make an appointment with you to do the initial fitting to place the order.

Step 4: After your shoes come in, we will do the follow up fitting for customization.

Have your primary care physician fill out this prescription & return or fax to The Prescription Shop

The Prescription Shop 601 W 11th St. Coffeyville, KS 67337 Phone (620) 251-1620 Fax (620) 251-4730

Prescription / Certifying Statement

Patients Name: ______________________________ Phone # _______________ Medicare # ________________________ DOB: __________________ Address: ______________________ City: _____________ ST/Zip____________

Prescription: Extra-depth footwear - 1 pair Male ________ w/ Inserts - 3 pair Female _______

Purpose (desired effects): Patient objective is to tranfer forces from high to low pressure areas, giving protection for the insensitive diabetic foot; absorb shock and reduce shearing; modify weight transfer patterns; limit motion of painful joints; facilitate ambulating and maximize comfort.

Statement of Certifying Physician for Therapeutic Shoes ICD 9 Code: 250.00 Non Insulin Dependent _______ 250.10 Insulin Dependent _______

I certify that all of the following statements are true: 1) This patient has diabetes mellitus 2) This patient has one or more of the following conditions: (Check all that apply) ___ Poor Circulation ___ History of pre-ulcerative callus ___ Foot deformity (bunions, hammertoes, etc.) ___ History of foot ulceration ___ History of partial or complete amputation of foot ___ Peripheral neuropathy w/ evidence of callus formation. 3) I am treating this patient under a comprehensive plan of care for his/her diabetes 4) This patient needs special shoes (depth shoes) because of his/her diabetes.

Physician Signature: ______________________________ Date: ___________ Name (Printed) ________________________________ Phone: _____________ Address: _____________________________________________________________ City: _____________________ ST _________ Zip: ___________________ UPIN# ________________________________________________________________

Bring Original to Our Store for Diabetic Footwear

Who Qualifies ?

What To Do Now ?

What is Covered ?

Step 2: Call Pleasant Hill Drug @540-4000 to schedule an appt.

Pleasant Hill Drug Store1905 N State Route 7Pleasant Hill, MO 64080(816) 540-4000(816) 540-4341 fax

Have your primary care physician fill out this prescription & return or fax to Pleasant Hill Drug