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Who Qualifies? Qualifies ? Who

Have your your primary primary care care physician physician fill Have fill out out this this prescription & return or fax to The Prescription Shop prescription & return or fax to Pleasant Hill Drug The Prescription Pleasant Hill DrugShop Store 1905 N State Route 7 601 W 11th St. Coffeyville, Pleasant Hill, KS MO 67337 64080 Phone (620) 251-1620 (816) 540-4000 (816) fax Fax 540-4341 (620) 251-4730

A Medicare patient with any of the conditions listed in step #2 on the right could be eligible for Therapeutic Shoes. Ask Your Doctor !!!

What What is is Covered? Covered ? Medicare will cover 80% of the allowed amount for: * One pair of extra depth shoes * Three pairs of inserts per Year Secondary Insurance may cover the remaining 20%

What Now? What To To Do Now ? Follow these simple directions to receive your Therapeutic Footwear: Step 1: See your doctor to have the prescription form to the right filled out. Step Prescription Shop Step 2: 2: Call CallThe Pleasant Hill Drug @@ 251-1620 schedule 540-4000toto scheduleananappt. appt. Step 3: We will verify your Medicare & Insurance coverage and make an appointment with you to do the initial fitting to place the order. Step 4: After your shoes come in, we will do the follow up fitting for customization.

Prescription / Certifying Statement Patients Name: ______________________________ Phone # _______________ Medicare # ________________________ DOB: __________________ Address: ______________________ City: _____________ ST/Zip____________

Prescription: Extra-depth footwear - 1 pair Male ________ w/ Inserts - 3 pair Female _______ Purpose (desired effects): Patient objective is to tranfer forces from high to low pressure areas, giving protection for the insensitive diabetic foot; absorb shock and reduce shearing; modify weight transfer patterns; limit motion of painful joints; facilitate ambulating and maximize comfort.

Statement of Certifying Physician for Therapeutic Shoes ICD 9 Code: 250.00 Non Insulin Dependent _______

250.10 Insulin Dependent _______

I certify that all of the following statements are true: 1) This patient has diabetes mellitus 2) This patient has one or more of the following conditions: (Check all that apply) ___ Poor Circulation ___ History of pre-ulcerative callus ___ Foot deformity (bunions, hammertoes, etc.) ___ History of foot ulceration ___ History of partial or complete amputation of foot ___ Peripheral neuropathy w/ evidence of callus formation. 3) I am treating this patient under a com prehensive plan of care for his/her diabetes 4) This patient needs special shoes (depth shoes) because of his/her diabetes.

Physician Signature: ______________________________ Date: ___________ Name (Printed) ________________________________ Phone: _____________ Address: _____________________________________________________________ City: _____________________ ST _________ Zip: ___________________ UPIN# ________________________________________________________________

Bring Original to Our Store for Diabetic Footwear


PH Diabetic Shoe Prescription Form