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Get NY Foot Performance Center Diabetic Footwear Prescription Form 2014-2024

Lude 2-digit ending) Patient must have at least ONE of the following Chart notes must substantiate medical necessity (A5500) DEPTH SHOES: (PLEASE CIRCLE ALL THAT APPLY): (V49.73 & 755.38) LOWER LIMB AMPUTATION, FOOT (V49.71 & 755.39) LOWER LIMB AMPUTATION, GREAT TOE (V49.72 & 755.39) LOWER LIMB AMPUTATION, LESSER TOE(S) (707.14) ULCER OF HEEL AND MIDFOOT (707.15) ULCER OF OTHER PART OF FOOT (707.9) HISTORY OF PRE-ULCERATIVE CALLUS (357.2) & (707.9) POLYNEUROPATHY IN DIABETES AND HISTORY.

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