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Molded Shoes and Cushioned Insoles
Author: Robert E. Dulberg, C.Ped. and O.S.T., Hallandale,
Florida
1-954-457-1202 or send email to Shoes@Netrunner.net
- Extra depth shoes along with plastizote insoles offer
pressure relief, shock absorption and friction reduction.
- Molded shoes are necessary for patients who have
structural deformities or have had previous plantar
ulcerations.
Medicare Therapeutic Shoe Program - 1995
- A "Statement of Certifying Physician" must be
signed by the patient's primary physician and/or
endocrinologist in order for the patient to receive
therapeutic shoes.
The following is the 1995 Statement of Certifying Physician
for Therapeutic Shoes.
Patient's Name and Medicare Number:
_____________________________________
I certify that all the following statements are true:
- The patient has diabetes (250.0)
- The patient has one or more of the following:
- History of partial or complete amputation of the
foot. (895.0)
- History of previous foot ulceration. (707.1)
- History of re-ulcerative callus (707.9)
- Peripheral neuropathy with evidence of callus
formation. (356.4)
- Existing foot deformity. (736.7)
- Poor circulation (443.9)
- I am treating this patient under a comprehensive plan of
care for his / her diabetes.
- Choose one:
- This patient needs depth shoes and inlays because of his
/ her diabetes.
- Due to serious foot deformity and diabetes, this patient
requires custom molded shoes.
- Physician's signature: _____________________ Date:
________________
- Physician's UPIN __ __ __ __ __ __
- Print: Physician's name:
- Print: Office Address:
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