Diabetic Shoe Referral Form

PROVIDER DIABETIC SHOE REFERRAL FORM

Physician Certification for Therapeutic Footwear

West Towne Pharmacy

1619 W. Market St. | JC, TN 37604

P: 423-926-9137 | F: 423-926-7321
Patient Name

First NameLast Name
Patient DOB

MonthDayYear
Date
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
ICD-10 code(s) that justify Medical Necessity

Other
Is the patient insulin dependent or non-insulin dependent?
I certify that I am treating this patient under a comprehensive plan of care for his/her diabetes, this patient requires therapeutic shoes (custom-molded shoes) because of his/her diabetes, and the above patient demonstrates one or more of the following (check all that apply):
IN ADDITION TO THIS REFERRAL FORM, WE ARE REQUIRED TO HAVE THE FOLLOWING IN ORDER TO PROVIDE DIABETIC SHOES TO YOUR PATIENT:
- Prescription for diabetic shoes and inserts (upload below, escribe, or fax)
- Copies of patient's medical insurance cards (upload below or fax)
- Office notes supporting the dispensing of diabetic shoes (the law requires a face-to-face encounter within 6 months of this referral) (upload below or fax)
Please upload a copy of the patient's insurance cards below or fax to 423-926-7321

Cancelof
Please upload a prescription for "1 pair of diabetic shoes and 3 pairs of inserts" below, escribe to West Towne Pharmacy, or fax to 423-926-7321

Cancelof
Please upload office notes supporting the dispensing of diabetic shoes (the law requires a face-to-face encounter within 6 months of this referral) below or fax to 423-926-7321

Cancelof
Physician Name

First NameLast Name
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Physician Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
NPI
Date

MonthDayYear
Date
PHYSICIAN SIGNATURE (MD OR DO ONLY)
Should be Empty: