Transcription of Physician’s Order for Diabetic Footwear
1 KEENE MEDICALPRODUCTS, CARE IS OUR BUSINESS Bringing Healthcare Home Since 1975. KEENE MEDICAL PRODUCTSC entral Intake Phone: 1-855-622-5556 Fax: 1-603-727-0996 Concord, NHP: 1-603-224-0135F: 1-603-228-4311 Bennington, VTP: 1-802-447-7468F: 1-802-447-1325 Gorham, NHP: 1-603-752-7694F: 1-603-752-5812 Burlington, VTP: 1-802-863-2114F: 1-802-660-9237 Keene, NHP: 1-603-357-3222F: 1-603-357-9469 Montpelier, VTP: 1-802-223-0665F: 1-802-223-0760 Lebanon, NHP: 1-603-448-5225F: 1-603-448-5671 Newport, VTP: 1-802-334-5160F: 1-802-334-8852 Nashua, NHP: 1-603-595-2097F: 1-603-595-2098 Rutland, VTP: 1-802-773-4574F: 1-802-773-8077 Portsmouth, NHP: 1-603-431-6006F: 1-603-431-9080St.
2 Johnsbury, VTP: 1-802-748-4185F: 1-802-748-4187 Statement of Certifying Physician1. The patient has diabetes mellitus:2 .QUALIFYING CONDITIONS:I have diagnoses and am including my notes showing that this patient has one or more of the following:3. I am treating this patient under a comprehensive plan for care of their This patient needs special shoes (Extra depth or custom molded) because of their This patient needs shoe inserts (Heat molded or custom fabricated) because of their 1 Type 2 Physician s Order for Diabetic FootwearPatient:Patient Date of Birth:Patient Phone:Prescription for Diabetic Shoes and of shoes prescribed:Regular Depth (A5500) - 1 pair, unless otherwise noted.
3 Of inserts prescribed:Heat Moldable (A5512) - 3 pairs, unless otherwise noted. ICD Notes and/or Special Instructions:Custom Fabricated (A5513) - 3 pairs, unless otherwise of partial or complete amputation of the of previous foot of pre-ulcerative neuropathy with evidence of callus Signature:Physician Name:Physician Address:Signature Date: NPI: Order Date:Physician Phone: Must be an or Signature:Physician Name:Physician Address:Signature Date:NPI: Physician Phone: Please sign and fax along with your PATIENT - 052 REV/TL - 11/17 Extra Depth (A5500) - 1 pair, unless otherwise noted.
