Directions for Completing the Forms for Medicare’s
Therapeutic Shoe Program for DiabeticsIMPORTANT: ONLY MEDICARE PART B PARTICIPANTS WHO HAVE CERTAIN DIABETIC CONDITIONS QUALIFY FOR THIS PROGRAM. All forms must be completed in full. Medicare will not accept forms that are missing information.
Section A:
This section should be filled out by the patient or guardian. It must be signed and dated. The insurance address and phone number requested are the address and phone number of the insurance company providing primary and/or secondary coverage. This information can frequently be found on the back side of the insurance card.
Section B:
This statement must be completed by your physician (M.D. or D.O.) and cannot be completed by your podiatrist (D.P.M.). The doctor that is your primary diabetic care physician is the best person to complete this form.
Please ensure that your doctor completes all of the questions, 1 through 4, and that he/she checks all the conditions that apply in question 2.
Please ensure that your doctor signs and dates the form. Please ensure that the UPIN number, address and phone number are filled out by the doctor’s office.
Section C:This section must be completed by your physician (M.D., D. O. or D.P.M.) and can be different from the physician that filled out Section B, the Statement of Certifying Physician.
Please ensure that your physician includes a diagnosis, purpose and prescription for both shoes and diabetic shoe inserts.
Please ensure that your doctor signs and dates the form. Please ensure that the UPIN number and phone number are filled out by the doctor’s office and that the doctor’s name is printed legibly.
Once all of your paperwork is filled out:
We recommend you call Foot Solutions to schedule an appointment time to ensure that we can provide you with the time and attention you deserve. The process will take between 30 minutes and an hour to fit extra-depth shoes and inserts. Our phone number is {xxx-xxx-xxxx}.
Foot Solutions cannot serve Medicare Part B patients who have not completed all required paperwork.
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Directions for Completing the Medicare Forms click here