Statement of Medical Necessity

(To be completed and signed by the physician       who manages your diabetic condition)

  

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Patient’s Name                                                             Date

  

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Patient’s Address                                                              Zip

  

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Patient‘s Phone #                                              Date of Birth

Patient Diagnosis

Is the patient Diabetic   Yes_____  No_____

Related Diagnosis_____________________

Diabetic Foot Conditions

Amputation (Part/Complete)Y                             N

History of Foot ulceration               Y                        N

Pre-ulcerative Callouses                  Y                           N

Peripheral Neuropathy/ Callouses   Y            N

Foot Deformity                                  Y                                         N

Poor circulation/diminished pulsesY                 N

Comprehensive Care Plan

  Is patient under a comprehensive

 Plan of care for their diabetes          Y                         N

 

  Does this patient need diabetic shoes

          (Extra-depth or custom molded)

                          Due to their diabetes              Y                            N

Managing physician, printed

  

___________________________________________

Managing physician, Signature

Phone #                                               NPI#

Medicare will not accept typed or stamped signature

  

Corrigan Podiatry Group

Dr. Tom Corrigan

(440) 871-3400

  

How can I get a pair of diabetic shoes?

Medicare Part B will cover 80% of

the cost of the following once

every calendar year. 

 

*One pair of Extra Depth shoes with three pairs of heat moldable soft inserts

 

OR

 

* One pair of custom molded shoes with   three molded inserts

 

If you have a secondary they should cover the other 20%.

 

Who qualifies for these shoes?

Any medicare patient with documentation from the physician who is managing the systemic diabetic condition stating that the patient is being treated under a comprehensive plan of care for diabetes and that the patient has one or more of the following conditions:

  

Poor Circulation / Cold Feet

Callouses with Peripheral Neuropathy

Foot Deformity (hammertoes/bunions/corns)

History of previous ulcers on the foot

Previous amputation of foot or part of foot

 

Simply ask our doctor or staff if you feel you or someone you know would benefit from professionally fitted diabetic shoes and inserts

  

 

Prescription for diabetic shoegear

(To be completed and signed by Dr. Tom Corrigan        who will order/fit your diabetic shoes)

 

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Patient’s Name                                                             Date

  

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Patient’s Address                                                              Zip

  

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Patient‘s Phone #                                              Date of Birth

  

Dx_________________________________

Prognosis____________________________

# Years pt has been Diabetic_____________

 

Shoe type:    Extra depth   or Custom molded

 

Inserts:    Heat moldable or Custom Scanned

 

Modifications: _______________________

_______________________________N/A

Shoe Size__________                     Male or Female

Shoe Width      M        Wide              Extra Wide

Catalogue number ____________________

printed

  

___________________________________________

Thomas A. Corrigan, DPM / Signature

 

28687 Center Ridge Road

Westlake Ohio 44145

                (440)871-3400       Fax (440)871-3433

NPI#:   1952484958