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.