• Mount Sterling Healthy Foot Center

    570 Indian Mound Drive Mount Sterling, KY 40353 Phone: (859) 498-3141 Fax: (859) 498-2434

  • Prescription for Therapeutic Shoes and Inserts

  • Patient Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Diabetic Depth Shoes, HCPC Code A5500*
  • Prefabricated Inserts-Multiple Density, HCPC Code A5512*
  • Custom Molded Inserts-Multiple Density, Molded to Model of Patient's Foot HCPC Code A5513*
  • Physical Exam: Neurological-Loss of Vibration Perception*
  • Physical Exam: Neurological-Loss of Protective Sensation*
  • Physical Exam: Vascular-Dorsalis Pedis (3=Normal), Choose Appropriate Level for RIGHT FOOT*
  • Physical Exam: Vascular-Dorsalis Pedis (3=Normal), Choose Appropriate Level for LEFT FOOT*
  • Physical Exam: Vascular-Posterior Tibial (3=Normal), Choose Appropriate Level for RIGHT FOOT*
  • Physical Exam: Vascular-Posterior Tibial (3=Normal), Choose Appropriate Level for LEFT FOOT*
  • Image field 31
  • Date Signed*
     - -

  • Must be the MD, DO, or other eligible prescriber who is actively treating the patient's diabetes (ie PA, Licensed Nurse Practioner, Clinical Nurse Specialist)

    NOTE: Shoes must be dispensed within 6 months from when the diabetes care was discussed by Certifying Physician with patient.

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Patient Date of Birth*
     - -

  • I certify that all of the following statements are true:

    1.) This patient has Diabetes Mellitus.

    2.) This patient has one or more of the following conditions.

    a) History of previous foot ulceration 

    b) History of pre-ulcerative callus

    c) Peripheral neuropathy with evidence of callus formation

    d) Foot deformity

    e) Poor circulation 

    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 shoes) because os his/her diabetes.

  • Please indicate patient condition present (check all that apply)*
  • Date Signed*
     - -
  • Format: (000) 000-0000.
  • Should be Empty: