ps diabetic shoe prescription form
DESCRIPTION
Print and use this form to take at your doctor's office to get the prescription you will need to have Medicare cover Diabetic Therapeutic Shoes.TRANSCRIPT
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.
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 ShoesICD 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 mellitus2) 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 diabetes4) 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
The Prescription Shop601 W 11th St.Coffeyville, KS 67337Phone (620) 251-1620Fax (620) 251-4730
Have your primary care physician fill out this prescription & return or fax to The Prescription Shop