Get Statement Of Certifying Physician For Therapeutic Shoes/inserts

Filling out the Statement of Certifying Physician for Therapeutic Shoes/Insert form is an important step in ensuring that individuals with diabetes receive the appropriate footwear necessary for their health. This guide provides detailed, step-by-step instructions on how to complete the form online, helping you support users in their needs.

Follow the steps to successfully complete the therapeutic shoes/insert certification form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient’s name in the designated field provided at the top of the form.
3. Verify and circle the applicable conditions from the list provided. This indicates which specific issues the patient is facing related to their diabetes.
4. Confirm and document that you are treating the patient under a comprehensive plan of care for their diabetes by checking the relevant statement.
5. Indicate the necessity for special shoes by checking the appropriate box that states the need for depth or custom-molded shoes due to the patient’s diabetes.
6. Fill in your name, credentials (M.D. or D.O.), address, NPI number, and phone number in the provided sections to validate your certification.
7. Finally, sign the form to complete the certification process.
8. Once all fields are completed, you may save changes, download, or print the form for submission.

Complete your therapeutic shoes/insert documentation online today.