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):_________________________________________




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