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Medicare diabetic shoes form

STATEMENT OF CERTIFYING PHYSICIAN FOR THERAPEUTIC SHOES/INSERTS 2025

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The document is a certification form for physicians to confirm that a patient with diabetes requires therapeutic shoes or inserts due to specific foot-related conditions. It emphasizes the importance of collaboration between the patient's primary physician and podiatrist in managing diabetic foot complications, as well as the eligibility criteria under the Medicare Therapeutic Shoe Bill.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the patient's name in the designated field at the top of the form.
Review and circle all applicable conditions that the patient has from the provided list, ensuring accuracy for each condition.
Confirm that you are treating this patient under a comprehensive plan of care for their diabetes by checking the relevant box.
Indicate whether special shoes are needed due to diabetes by marking the appropriate option.
Fill in your name, designation (M.D. or D.O.), address, NPI number, and phone number in the specified fields.
Finally, sign and date the form to certify its accuracy before submission.

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2011	4 Satisfied (38 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Can you get a prescription for shoes?

The doctor who treats your diabetes must certify your need for therapeutic shoes or inserts. A podiatrist (foot doctor) or other qualified doctor must prescribe the shoes or inserts, and you must get the shoes or inserts from one of these: A podiatrist. An orthotist.

How do I get Medicare to pay for shoes?

Medicare will only cover your orthopedic 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.

Can nurse practitioners write for diabetic shoes?

This practitioner must be knowledgeable in the fitting of diabetic shoes and inserts. The prescribing practitioner may be a podiatrist, M.D., D.O., physician assistant, nurse practitioner, or clinical nurse specialist. The prescribing practitioner may be the supplier (i.e., the one who furnishes the footwear).

How often will Medicare pay for orthopedic shoes?

This may include conditions such as diabetic neuropathy or Charcot foot. Each calendar year, Medicare Part B covers the furnishing and fitting of either one pair of extra-depth shoes or one pair of custom-molded shoes and inserts.

What type of doctor prescribes shoe inserts?

A podiatrist will prescribe orthotics based on medical problems or pain a patient may be experiencing. The podiatrist will also watch how a patient moves (known as gait analysis) and consider other issues like their level and type of activity, foot type, and the movement of their ankle, knee and hip.

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How do you qualify for orthopedic shoes?

A medical professional must diagnose an individuals medical issues and provide a Letter of Medical Necessity (LMN) for the individuals expense in purchasing orthopedic shoes to be considered eligible for reimbursement with a consumer-directed healthcare account.