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Dahl Medical Supply - Diabetic Shoes Prescription PDF

Step-By-Step Instructions to qualify for Therapeutic Footwear through Medicare

We are looking forward to helping you protect your feet from breakdown and/or ulceration by using properly fitted diabetic footwear. Please follow these instructions to help us speed up getting you into your new shoes.

1. Take the enclosed Diabetic Footwear Prescription Form (Page 2 in PDF Link Below) to either your M.D., D.O., Endocrinologist or Podiatrist to complete. The prescription must be specific as to the type of footwear and inserts you require. Please remember this prescription is only valid for 90 days from the date it is signed. You must receive your new items within 90 days of the prescription date, so please don’t delay in calling us for a fitting appointment.

2. Take the enclosed Statement of Certifying Physician (Page 3 in PDF Link Below) to your Medical Doctor who is treating you for diabetes and have them complete this form. This form cannot be signed by anyone except an M.D. or D.O.

3. PLEASE NOTE THAT YOUR DOCTOR MUST ALSO SEND US CLINICAL CHART NOTES FROM YOUR VISIT, AND THEY MUST INCLUDE KEY INFORMATION REQUIRED BY MEDICARE. This is explained further in the Guidelines for Clinical Notes (Page 4). We must emphasize Medicare requires this additional information and without it, Medicare will deny our claim for your shoes and inserts, thereby making you responsible for the charges. Your Primary Care Doctor or Endocrinologist may not be comfortable with documenting your foot condition(s) and may require you to first obtain this detailed information from your Podiatrist. If provided by a non-M.D. or D.O., your PCP/Endocrinologist must sign, date and indicate agreement with their findings.

4. Once all of your paperwork is complete, contact one of our 12 clinics for a fitting appointment. Our Practitioner will assist you with the selection of footwear and diabetic inserts prescribed by your doctor.

IMPORTANT NOTE:

In order for this form to be valid, it must be accompanied by DETAILED CLINICAL NOTES regarding the above indicated foot conditions!

GUIDELINE FOR CLINICAL NOTES

Dear Primary Care Doctor (or Endocrinologist): Thank you for helping our mutual patient receive Diabetic Footwear. Medicare has for years required you to fill out and submit the Statement of Certifying Physician (SCP). However, over the last few years Medicare has increased the paperwork requirements on suppliers and referring physicians.

WE MUST HAVE RECENT CLINICAL NOTES (WITHIN SIX MONTHS OF THE DATE YOU SIGN THE SCP) FROM YOU THAT SUPPORT THE FOUR MAJOR PORTIONS OF THE STATEMENT OF CERTIFYING PHYSICIAN. IF THE CLINICAL NOTES DO NOT SUPPORT THE STATEMENT OF CERTIFYING PHYSICIAN, THE STATEMENT IS RENDERED VOID.

YOU MAY SUBSTITUTE CHART NOTES FROM THE PATIENT’S PODIATRIST, BUT YOU MUST SIGN, DATE AND INDICATE AGREEMENT WITH THEIR FINDINGS.

CLINICAL NOTES GUIDELINES:

1. Must explicitly certify that the patient has diabetes and assign an applicable ICD-10 code. Results of tests, exams, findings must be in the notes (i.e. blood glucose levels and A1c).

2. Must explicitly document a foot exam and one or more of the required conditions.

THIS INCLUDES THE DETAILS OF TESTS, EXAMS, INSPECTIONS, FINDINGS, ETC. THAT WERE USED TO CONCLUDE THE CONDITION EXISTS.

You may rely on findings of other doctors, such as the patient’s Podiatrist, but you must sign, date and make a note on their document indicating your agreement with their findings and then send that document along with the Statement of Certifying Physician that you have also completed, signed and dated.

If you are noting a particular problem, such as a foot deformity, please specify which foot and the type and location of the problem (e.g. Patient has bilateral hammer toes #2-#5). The following are commonly found foot conditions that place a diabetic patient at increased risk and thus qualify them to receive therapeutic footwear through Medicare and other payers:

Lower limb amputation, toes, foot or limb

Ulcer of foot History of pre-ulcerative callus – specify location of callus Polyneuropathy in diabetes and History of pre-ulcerative callus

Claw toe

Hammer toe

Hallux valgus and/or Bunion

Hallux rigidus

Deformity of toe or foot

Charcot Arthropathy

Atherosclerosis of the extremities

Click on the link below for a printable Diabetic Shoes Prescription form that should be filled out by a Certifying Physician.