Footwear form 2026

1. Click ‘Get Form’ to open the footwear form in the editor.
2. Begin by selecting the appropriate option for your request: New Certification, Renewal, or Change of Employment. Check the corresponding box.
3. Fill in your Medicaid Provider Name, Medicaid Provider Number, and National Provider Identifier (NPI) in the designated fields.
4. List the names of Certified Orthotist(s), Prosthetist(s), or Pedorthist(s) involved in this request.
5. Indicate the relationship of the certified individual to your company by checking either Owner or Employee. If neither applies, provide an explanation in the space provided.
6. Detail all other locations where certified individuals are employed and dispensing shoes.
7. Attach a copy of current certification for at least one employee or owner by checking the appropriate certifying body.
8. If applicable, list any certified fitters and attach their licenses as well.
9. For changes in employment, specify if it’s for a new employee or one who has left, including relevant dates and signatures.

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