(see “Medicare Coverage of Therapeutic Footwear for People with Diabetes”) Patient Name: National Diabetes Education Program (NDEP) http://ndep.nih.gov …
NDEP | National Diabetes Education Program
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Certifying physician may be different from prescribing physician Print this page and complete the form by hand see Medicare Coverage of Therapeutic Footwear for People with Diabetes
Patient Name:
HIC :
Address:
I certify that all of the following statements are true: 1 This patient has diabetes mellitus - ICD-9 Code: _________________ ICD-9 diagnosis codes 25000-25091 This patient has one or more of the following conditions check all that apply: _____ _____ _____ _____ _____ _____ 3 4 History of partial or complete amputation of the foot Peripheral neuropathy with evidence of callus formation History of previous foot ulceration Foot deformity History of pre-ulcerative callus Poor circulation
2
I am treating this patient under a comprehensive plan of care for his/her diabetes This patient needs special shoes depth or custom-molded shoes and/o 
r inserts because of his/her diabetes
Certifying Physician Information
Signature:
Date:
Name:
DEA :
http://wwwndepnihgov/resources/feet/certifichtm
2/23/2005
NDEP | National Diabetes Education Program
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Medicare UPIN :
Medicaid Provider :
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National Diabetes Education Program NDEP http://ndepnihgov NIDDK, National Institutes of Health, Bethesda, MD A Joint Initiative of the National Institutes of Health and the Centers for Disease Control and Prevention
NDEP Home | About Diabetes | Resources for Health, Education, and Business Professionals Awareness Campaigns | Partnerships | About NDEP | Whats New? | Contact Us | Site Map DHHS Home | NIH Home | NIDDK Home | CDC Home Search NIDDK | Privacy Statement | Disclaimers
http://wwwndepnihgov/resources/feet/certifichtm
2/23/2005
Source:diabetesmonitor.com
