Diabetic Shoe Referral Form

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.
ICD-10 code(s) that justify Medical Necessity*

E11.9E10.9Other
Is the patient insulin dependent or non-insulin dependent?*

NIDDMIDDM
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):*

History of partial or complete amputation of the footHistory of previous foot ulcerationHistory of pre-ulcerative callusPeripheral Neuropathy with evidence of callus formationFoot deformityPoor circulation
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.
Physician Fax Number*
Please enter a valid phone number.
NPI*
Date*

MonthDayYear
Date
PHYSICIAN SIGNATURE (MD OR DO ONLY)*

Clear
Should be Empty: