Transcription of Prescription for Therapeutic Footwear Diabetic ...
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Prescription for Therapeutic Footwear Diabetic ...
*PLEASE FAX TO: Great Steps O&P Solutions 320-229-1671* *PLEASE FAX TO: Great Steps O&P Solutions 320-229-1671* Edema ( ) Neuroma ( ) Corn(s) (700) Ankle Instability ( ) Drop Foot ( ) Posterior Tib. Disorder ( ) Peripheral Vascular Disease ( ) Neuropathy ( ) Prescription for Therapeutic Footwear (MD, DO, DPM, NP, PA, CNP) Patient Name: _____ Chart #: _____ DOB: _____ Today s Date: _____ Check all that apply: Diabetes Mellitus: ICD-9: _____ (ICD-9 codes ) Hammertoe(s) ( ) Bunion(s) ( ) Ulcer(s) (707. 8/9/14/15) Callus(es) (700 s) Amputation(s) (896. - 1/2) Charcot Deformity ( ) Plantar Fascitis ( ) Other: _____ The patient requires: Diabetic Footwear , non custom (A5500) 1 pair (unless otherwise indicated) With: Custom molded inserts (A5513) 3 pairs (unless otherwise indicated) Lesions requiring offloading: L 1 2 3 4 5 R 1 2 3 4 5 Non custom, heat moldable inserts (A5512) 3 pairs (unless otherwise indicated) Toe Filler (L5000) Comments: _____ _____ _____ Clinician Name: _____ Signature: _____ ____ Date: _____ Diabetic Verification Form (MD or DO Only) Patient Name: _____ DOB: __
*PLEASE FAX TO: Great Steps O&P Solutions – 320-229-1671* *PLEASE FAX TO: Great Steps O&P Solutions – 320-229-1671* Edema_____ (782.3)
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