Statement of Certifying Physician
ATTENTION DOCTOR (M.D. or D.O.): Medicare requires that your clinical chart notes from the last 5 months document a diabetes diagnosis, a foot exam, and the risk factors checked below.
2. CLINICAL CERTIFICATION (To be completed by Physician)
I certify this patient has the following (check all that apply):
History of foot ulceration
History of pre-ulceration callus
History of partial/complete amputation
Foot Deformity (Hammertoe/Bunions)
Peripheral neuropathy with callus
Poor Circulation
3. PRESCRIPTION FOR THERAPEUTIC FOOTWEAR
1 Pair Diabetic Shoes (A5500)
1 Pair Custom Made Shoes (A5501)
Only if patient cannot fit into standard shoe
3 Pairs Custom Molded Inserts (A5513)
2 Pairs Custom Inserts (A5513) (for Custom Shoes)
3 Pairs Heat Molded Inserts (A5512)
L5000 Insert (Toe Filler):
Right
Left
Both
4. PHYSICIAN SIGNATURE (M.D. or D.O. Only)