These forms are required if you plan on going through insurance on our Pedorthic side:
Prior to your appointment please complete:
a) Patient Facesheet **You may just submit this form electronically, no need to print**
b) HIPAA Privacy Receipt Acknowledgement
Medicare Diabetic Shoe/Insert Coverage (print forms and follow steps below)
This form explains qualifying conditions and step-by-step instructions (diabetes only does not qualify, you must have a severe foot condition)
Print and take these 2 forms with you to your next appointment with the M.D. or D.O. treating your Diabetes
a) What Medicare Requires from the Certifying MD/DO
b) Statement of Certifying Physician for Therapeutic Footwear
