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  • Diabetic Shoe Referral Form (2)

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FAX: (866) 7158480 Statement of Certification & Physician Prescription Therapeutic Diabetic Shoes Start Date: PATIENT INFORMATION: DOB: PHYSICIAN INFORMATION: I certify I have evaluated M/F: Name:.

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Code A5507 is only to be used for not otherwise specified therapeutic modifications to the shoe or for repairs to a diabetic shoe(s). Deluxe features must be coded using code A5508.

Diabetic Shoes (A5500)

A5500 is a standardized code for Medicare and other health insurance providers to provide healthcare claims. Diabetic shoes (sometimes referred to as extra depth, therapeutic shoes or Sugar Shoes) are intended to reduce the risk of skin breakdown in diabetics with pre-existing foot disease.

Type 2 diabetes mellitus with foot ulcer E11. 621 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2023 edition of ICD-10-CM E11.

How Individuals Qualify history of partial or complete foot amputation. history of previous foot ulceration. history of preulcerative callus. nerve damage because of diabetes with signs of problems with calluses. poor circulation. foot deformity.

The doctor who treats your diabetes must certify your need for therapeutic shoes or inserts.

If you are diabetic and have Medicare and Medicaid, you could be eligible for a pair of shoes and 3 pairs of moldable insoles. It is that easy! All you have to do is bring in your insurance cards and a prescription from your doctor.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232