Therapeutic Shoes Request

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A certification for therapeutic shoes for providers to use is included in the Diabetes Planned Visit Notebook.

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Certification for Therapeutic Shoes

Patient
Name _______________________________________________
HIC#   _______________________________________________

I certify that all of the following statements are true:
____ This patient has diabetes mellitus
This patient has one or more of the following conditions (check all that apply)
____ History of partial or complete amputation of foot
____ History of previous foot ulceration ____ History of pre-ulcerative callus
____ Peripheral neuropathy with evidence of callus formation
____ Foot deformity  ____ Poor circulation
I am treating this pt under a comprehensive plan of care for his/her diabetes.
This patient needs special shoes (depth or custom-molded shoes) because of
his/her diabetes.

Physician signature: ____________________________________________
Date signed: __________________________________________________
Physician Name (print): __________________________________________
Physician address: _____________________________________________
Physician UPIN: ________________________________________________

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