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Custom Inserts Shoes Order Form

FILL FIRST BOX OR ATTACH PT DEMOGRAPHIC SHEET

    Date of Birth*

    Phone Number*

    Zip Code*

    Insurance Name*

    Insurance ID*

    ICD-10 Diagnosis Code:

    The Patient must have a Documented Hx of one or more of the following to meet Medical Necessity History of previous foot ulceration

    Physician’s Order:

    Clinical Evaluation:

    I am currently treating this patient under a comprehensive plan of care for diabetes mellitus. This patient needs extra depth shoes with multiple density inserts because of his/hers diabetes. I certify that all of the conditions checked above are in my doctor’s notes.
    Signature*

    Date*

    Physician Information: Dr. Name

    UPIN #

    state*

    Zip Code*

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