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Diabetic Shoes Order Form & Statement of Certifying Physician

You can download the PDF version of the form by clicking the download button below.

Download PDF Form

PHONE: 718-436-6088 • FAX: 718-436-3649 • EMAIL: DMEORDERS@MEDARTS.NET
ADDRESS: 5504 13TH AVE BROOKLYN, NY 11219

You can also Fill out the form below

  1. This form must be completed BY THE PHYSICIAN TREATING THE PATIENT FOR DIABETES
  2. The PHYSICIAN TREATING THE PATIENT FOR DIABETES must provide clinical notes documenting the patient’s diabetes management and the medical necessity for diabetic shoes
  3. A prescription from the Physician treating the diabetes OR Podiatrist is required, specifying: 
    • Diabetic Depth Inlay Shoes (1 pair allowed/year)

                 AND

    • Heat Molded Multiple Density Inserts (max 3 pairs allowed/year)

PATIENT INFORMATION

INSURANCE INFORMATION

SHOE & INSERT ORDER (specify quantity)

STATEMENT OF CERTIFYING PHYSICIAN (select all that apply)

1. PATIENT HAS DIABETES MELLITUS

2. PATIENT HAS 1 OR MORE OF THE FOLLOWING CONDITION(S):

CERTIFICATE OF MEDICAL NECESSITY

***FAX FORM TO 718-436-3649 OR SEND ELECTRONIC PRESCRIPTION DIRECTLY FROM YOUR EMR SYSTEM OR FROM PARACHUTE HEALTH***