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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  

Print and use this form to take to your doctor's office and have it filled out as a prescription for you to receive Medicare covered diabeti...

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