Statement of Certifying Physician for Therapeutic Shoes

Patient:             Date of Birth

MCR or MCD Number #:

I certify that all of the following statements are true:

1. This patient has diabetes mellitus – ICD-10 Code:

2. This patient has one or more of the following conditions.

CHOOSE ALL THAT APPLY & have medical records attached fully describing the medical necessity for the request of diabetic shoes.

Documentation of the above indicated condition is required. Please send medical records.

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

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

Physicians Signature:          Date 
                     Please print & sign or attach your digital signature

Physician Name:           NPI:  

MCD Provider Number: Phone:

In order to meet Medicare & Medicaid criterion 2, the certifying physician must either:
i.Personally document one or more of criteria a – f in the medical record prior to signing the certification statement; or
ii.Obtain, initial, date (prior to signing the certification statement), and indicate agreement with information from the medical records of a podiatrist, other M.D or D.O., physician assistant, nurse practitioner, or clinical nurse specialist that documents one of more of criteria a – f.

Healthcare Professionals Only
History of pre-ulcerative callus
History of partial or complete amputation
Foot deformity
Poor circulation
Peripheral neurapathy with evidence of callus formation