Diabetic Shoe Order Form. A statement of certifying physician completed by the md/do treating your diabetic condition, signed within the last 3 months. The ordering provider can be your doctor, podiatrist, nurse practitioner, physician assistant or clinical nurse specialist.
Pin on Diabetic Foot
Web a standard written order (page 3) this document specifies the item(s) that the ordering provider is requesting be provided to you. The ordering provider can be your doctor, podiatrist, nurse practitioner, physician assistant or clinical nurse specialist. Total contact orthoses order form. • open/download word docx file. Toe filler l5000 order form. Abn for shoes & inserts. Web podiatric packet for shoes & inserts. Web coverage of therapeutic shoes for persons with diabetes is based on social security act §1862(a)(1)(a) provisions (i.e. Primary/managing physician packet for shoes and inserts. A5512 heat moldable insole order form.
Web a standard written order (page 3) this document specifies the item(s) that the ordering provider is requesting be provided to you. The ordering provider can be your doctor, podiatrist, nurse practitioner, physician assistant or clinical nurse specialist. Web coverage of therapeutic shoes for persons with diabetes is based on social security act §1862(a)(1)(a) provisions (i.e. This template is designed to assist a physician (md or do) in completing a statement of certifying physician for therapeutic shoes, modifications, and inserts for persons with diabetes to meet requirements for medicare eligibility and coverage. Web a standard written order (page 3) this document specifies the item(s) that the ordering provider is requesting be provided to you. • open/download word docx file. Total contact orthoses order form. A5512 heat moldable insole order form. Primary/managing physician packet for shoes and inserts. Web check out our resource center to find additional documentation and forms that you’ll need for participation and reimbursement in the diabetic shoe program. Web podiatric packet for shoes & inserts.
