Diabetes Planned Visit Notebook

12. Therapeutic Shoes Request

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

Certification for Therapeutic Shoes

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: ________________________________________________

Page last reviewed October 2014
Internet Citation: 12. Therapeutic Shoes Request. October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/diabnotebk/diabnotebk12.html