Get Diabetic Shoe Referral Form (2)

Filling out the diabetic shoe referral form online can streamline the process of obtaining necessary therapeutic footwear for individuals with diabetes. This guide provides comprehensive instructions on how to accurately complete each section of the form to ensure proper submission.

Follow the steps to effectively complete the form.

1. Press the ‘Get Form’ button to retrieve the diabetic shoe referral form and open it in your chosen editor.
2. Enter the patient information, including their date of birth and other relevant details. Ensure all fields are filled accurately to prevent delays in processing.
3. Provide the physician's information, including their name, address, city, state, ZIP code, and contact phone numbers. This ensures that the referral is correctly attributed to the healthcare provider.
4. In the certification section, confirm that you have evaluated the patient's feet and have noted the need for diabetic shoes, checking the appropriate gender box.
5. Complete the products prescribed section by indicating the type and number of diabetic shoes and inserts required based on the patient's specific needs.
6. Document the diabetes diagnosis code, ensuring it falls between 249.00 and 250.93, as required for proper processing.
7. Fill in the dates for the most recent exam where diabetes was discussed and the last foot exam, specifying the format as MM/DD/YY.
8. Certify that the patient requires diabetic shoes and multiple density inserts by checking 'YES' for both statements. Additionally, check all applicable secondary foot conditions that must be documented.
9. Sign the form with your name, including the physician signature, ensuring no stamps are used, and provide the National Provider Identifier (NPI).
10. Return the completed form along with a copy of the patient’s medical record associated with the requested product. Save your changes, download a copy for your records, or share the completed form as needed.

Ensure you fill out your diabetic shoe referral form online today for a smoother process in obtaining therapeutic footwear.