Therapeutic Shoes for Persons with Diabetes Statement of Certifying Physician

All fields are required by payer to be completed by the certifying physician

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Name

First

Middle

Last

DOB

Medicare/Ins ID:

Date of Last Diabetic Exam

This patient has diabetes mellitus

This patient has one or more of the following conditions (check all that apply)

I am treating this patient under a comprehensive plan for his/her diabetes.

This patient needs special shoes (depth or custom-molded shoes) because of his/her diabetes.

I M.D. (must

Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

NPI

Signature

Clear Signature

Date