Certifying Physician Statement for Therapeutic Footwear
Patient Name
Date of Birth
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I certify the following statements are true:
The patient has one or more of the following conditions that justify the medical need for therapeutic footwear (select all that apply):
Yes
Foot deformity
History of partial or complete amputation of the foot
History of pre-ulcerative callus
History of previous foot ulceration
Peripheral neuropathy with evidence of callus formation
Poor circulation
I am treating this patient under a comprehensive plan of care for his/her diabetes.
Yes
No
This patient needs special shoes (depth or custom molded shoes) because of his/her diabetes
Yes
Physician Name
NPI Number
Address
Phone Number
Signature
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Standard Written Order (SWO)
Diagnosis (ICD-10 Code(s)
E11.8
E11.9
E11.621
E11.40
E11.59
Other
Ordered Items (CPT Codes & Quantity)
(select shoes and inserts)
A5500 - Depth-inlay diabetic shoes -1pair
Left
Right
Bilateral
A5513 - Multi density inserts, custom fabricated –3pair
Left
Right
Bilateral
A5514 - Custom-molded inserts -3pair
Left
Right
Bilateral
A5512- Heatmoldable -3pair
Left
Right
Bilateral
L5000- Toe Amputation
Left
Right
Bilateral
Physician Name
NPI Number
Address
Phone Number
Signature
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