Here's how it works
01. Edit your diabetic shoes prescription example online
Type text, add images, blackout confidential details, add comments, highlights and more.
02. Sign it in a few clicks
Draw your signature, type it, upload its image, or use your mobile device as a signature pad.
03. Share your form with others
Send it via email, link, or fax. You can also download it, export it or print it out.
How to use or fill out diabetic footwear prescription form 2021 with our platform
- Click ‘Get Form’ to open the diabetic footwear prescription form 2021 in the editor.
- Begin by entering the patient's name, ID number, and date of birth in the designated fields at the top of the form.
- Indicate the appropriate ICD-10 code for the patient's diagnosis. Ensure that you include all relevant codes as insurance requires them for patient records.
- In the 'Covered Procedures' section, check all applicable boxes that pertain to lower limb amputations or foot ulcers.
- For inserts, indicate any conditions present by checking the corresponding boxes under 'For Inserts Indicate Below'.
- Select the number of pairs needed for depth shoes and custom inserts from the options provided.
- Complete any special Rx instructions if necessary and ensure that all physician information is filled out accurately at the bottom of the form.
Start filling out your diabetic footwear prescription form today for free using our platform!
Fill out diabetic footwear prescription form 2021 online
It's free
It's free
See more diabetic footwear prescription form 2021 versions
We've got more versions of the diabetic footwear prescription form 2021 form. Select the right diabetic footwear prescription form 2021 version from the list and start editing it straight away!
Got questions?
We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.
Contact us
How can I get a free pair of diabetic shoes?
Most insurance companies, including Medicare, cover the cost of one pair of diabetic shoes as well as up to 3 pairs of plastazote inserts per calendar year. *Co-payments, deductibles, and some restrictions may apply. Use the button below to download MEDICARE prescription form.
What qualifies you for diabetic shoes?
Candidates for the Diabetic Shoe Program should docHub that you have diabetes, are undergoing treatment and require diabetic shoes as part of the treatment, and have at least one of the following conditions in one or both feet: Partial or complete amputation of the foot. Foot ulceration history. Foot deformity.
What equipment is needed for a diabetic foot exam?
Includes polypropylene case with either a bi-directional (MD2) or non-directional (D900) Dopplex Doppler and 8 Mhz probe, sphygmomanometer, arm/ankle, large and small toe cuff, 10g monofilament, educational video, ABPI and TBPI guide, tube of gel and headphones.
What to document for diabetic shoes?
Physician complete all required paperwork: o Statement of docHubing Physician for Therapeutic Shoes o Prescription/Standard Written Order o Office Visit Notes from prescribing provider and physician that treats your diabetes. These evaluations must be within 6 months prior to receiving your shoes and/or inserts.
Does Medicare pay for a pair of shoes for diabetics?
Medicare will only cover your therapeutic shoes if your doctors and suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare. If your doctors or suppliers arent enrolled, Medicare wont pay the claims they submit.
Security and compliance
At DocHub, your data security is our priority. We follow HIPAA, SOC2, GDPR, and other standards, so you can work on your documents with confidence.
Learn more
People also ask
What documentation is needed for diabetic shoes?
o Statement of docHubing Physician for Therapeutic Shoes o Prescription/Standard Written Order o Office Visit Notes from prescribing provider and physician that treats your diabetes. These evaluations must be within 6 months prior to receiving your shoes and/or inserts.
What is the code A5500 for diabetic shoes?
An A5500 shoe is an off-the-shelf shoe manufactured to accommodate particular needs for diabetics and that has met all the specifications to qualify for reimbursement through Medicare and other health insurances providers. The A5500 is a standardized code used by these entities for healthcare claims.
What are the Medicare guidelines for diabetic shoes 2025?
Your therapeutic shoes under Medicare arent entirely free. If enrolled in Original Medicare, you must pay a monthly premium starting at $185 in 2025, depending on your income. You also have to meet a $257 annual deductible. Once you do, Part B pays for 80% of the cost of the shoes.
