Statement of certifying physician for therapeutic shoes 2025

1. Click ‘Get Form’ to open the statement of certifying physician for therapeutic shoes in the editor.
2. Begin by entering the patient's name and HIC number at the top of the form. Ensure accuracy as this information is crucial for identification.
3. In section 1, confirm that the patient has diabetes mellitus by checking the appropriate box. This is a vital requirement for therapeutic shoe eligibility.
4. Proceed to section 2, where you will circle all applicable conditions from the list provided. This includes options like history of foot ulceration or peripheral neuropathy.
5. In section 3, affirm that you are treating the patient under a comprehensive care plan for their diabetes. This demonstrates ongoing management and support.
6. Finally, in section 4, indicate that special shoes are necessary due to the patient's diabetes. Sign and date the form at the bottom, ensuring your name is printed clearly as an M.D. or D.O.

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