Statement of Certifying Physician (MD or DO) for Therapeutic Shoes
(Must be accompanied by Signed Progress Notes from the last visit and contain a
Comprehensive Plan for the treatment of Diabetes)
(Condition marked below must be detailed in the notes)
Patient Name:___________________________________ Phone#:___________________
I certify the following statements are true: 1. This Patient has Diabetes mellitus. 2.This Patient has one of the
following conditions. Check all that apply:
_ a) History of partial or complete amputation of the foot. (Stated in Progress Notes)
_b) History of previous foot ulceration. (Stated in Progress Notes)
_c) History of pre-ulcerative callus. (Stated in Progress Notes)
_d) Peripheral neuropathy with evidence of callus formation. (Stated in Progress Notes)
_e) Foot deformity (Stated in notes i.e.: Bunion, Claw Toe, Hallux Valgus etc.)
_f) Poor Circulation (Stated in notes i.e.: Weak Tibial pulse, Diminished Pedal Pulse)
3. I am treating this Patient under a comprehensive plan of care for his/her diabetes.
4. This Patient needs special shoes & inserts because of his/her diabetes.
Physician Signature:________________________________________ Date:____________
Physician name printed (must be DO or MD):_________________________________________
NPI:_________________________________________
Physician Address:_______________________________________________________________
Prescription for Therapeutic Footwear:
__Extra Depth Diabetic Shoes (5500)-1pr. __Heat Moldable Inserts (5512)-3pr
ICD Codes/Special Instructions:____________________________________________________
Professional Name:______________________________________ Phone#:_________________
Professional Signature:____________________________________NPI:____________________
1410 KINGS HWY N., CHERRY HILL, NJ 08034 PHONE: 856-428-2201 FAX: 428-2241