Medicare diabetic shoes form 2026

1. Click ‘Get Form’ to open the Medicare diabetic shoes form in our platform.
2. Begin by entering the patient's name and date of birth in the designated fields. Ensure accuracy for proper identification.
3. Fill in the patient's address, including city, state, and zip code. This information is crucial for Medicare processing.
4. Input the Medicare/HIC number and phone number. These details help verify coverage eligibility.
5. In the certification section, check all applicable conditions that apply to the patient’s diabetes. This includes any history of foot issues or deformities.
6. Document the date of service when you last saw the patient and ensure your signature as a physician is included at the bottom of the form.
7. Complete the prescription section by circling one option for the type of shoes and inserts needed, followed by your comments if necessary.
8. Finally, sign and date this section to confirm all information is accurate before submitting it via fax as instructed.

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