2014 DIABETIC FOOTWEAR PRESCRIPTION FORM-2026

1. Click ‘Get Form’ to open the 2014 DIABETIC FOOTWEAR PRESCRIPTION FORM in the editor.
2. Begin by entering the patient's name, ID number, and date of birth in the designated fields at the top of the form.
3. Indicate the appropriate ICD-9 code for the diagnosis. Ensure that you include a two-digit ending as specified.
4. In the section labeled 'Patient must have at least ONE of the following', circle all applicable conditions that justify medical necessity for diabetic footwear.
5. For inserts, check the number of pairs required under both direct mold inserts and custom inserts sections.
6. Fill out any additional modifications needed, such as custom toe fillers or rocker bottom soles, ensuring to circle only one option where indicated.
7. Complete the special Rx instructions if necessary and provide prescribing physician information including name, signature, date, address, NPI number, and phone number.

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