ASK YOUR DOCTOR TO FILL OUT THIS FORM

AND RETURN IT TO MILBURN PHARMACY

Patients Name:_________________________________ Phone:_______________________

Medicare #:___________________ Medicaid #:___________________ D.O.B.:__________

Other insurance: ____________________ Phone #:________________ Policy #:__________

Address:____________________________ City:_______________ State:_____ Zip:______

Color:_________________ Lace or Velcro:_____________ Current size:______ Width:____

Prescription: A5500KX Footwear, in-depth - 1 pair (2) Male_______

A5512KX Orthotics - 3 pair (6)         Female_______

L1902 Ankle Foot  Gauntlet - 1 pair (2)

PURPOSE: Patient objective is to transfer forces from high to low pressure areas, giving

protection for the insensitive diabetic foot, absorb shock and reduce shearing, modify weight

transfer patterns, limit motion of painful joints, facilitate ambulating and maximize comfort.

Statement of certifying physician for therapeutic shoes

ICD.9 code:   250.00____NIDDM___ 250.01____IDDM___       250. __other_____

Length of Need__________________          Prognosis_____________________________

I Certify That all of the Following are True:

1. This patient has diabetes mellitus

2. This patient has one or more of the following conditions (check all that apply)

__Poor circulation __History of pre-ulcerative callus

__Foot deformity __History of partial/complete amputation of the foot

__History of foot ulceration

__Peripheral neuropathy with evidence of callus formation

3. I am treating this patient under a comprehensive plan of care for his/her diabetes

4. This patient needs special shoes (depth shoes) because of his/her diabetes

Physician Signature:______________________________________ Date:______________

Physician Address:____________________ City:_______________ State____ Zip:______

Physician Phone___________________  UPIN#__________________________________