WebBasic Patient Packet - Current AuBurn Pharmacies Website

Diabetic Shoes & Inserts Prescription Form

WebOrder and Return Forms Whether you want to order shoes, custom inserts, or adjust/repair an item, use one of these order forms to make your purchase. Simply print the order … WebFor diabetic shoes and inserts to be covered by Medicare, the patient’s medical record must contain sufficient information about the patient’s medical condition to substantiate the necessity for the type and quantity of items ordered … designer seating inc

Therapeutic Shoes for Persons with Diabetes CMS

WebMEN’S SHOE ORDER 90 Trail Worker Oil Black* Whiskey Style No. Descripti Color 19 Casual Mary Jane Black* Cognac 17 Sport Sprinter Black White 31 Sport Walker Black White 33 Casual Mary Jane Black Stretch 51 Casual Dress Black* Cognac 55 Trail Boot Oil Black Whiskey 63 Casual Comfort Black Stretch 67 Casual Comfort Black 75 Casual … Web1) The patient has diabetes . 2) The patient is being treated under a comprehensive plan of care for diabetes . 3) The existence of at least one of the 6 conditions listed above . Ralph Baker’s Shoes 428 North Main St. Salisbury, NC 28144 . … WebDiabetic Shoe Order NAS Investments of Georgia, Inc Citizens Pharmacy 5325 Atlanta Highway Flowery Branch, GA 30542 ... This patient needs special shoes (depth or custom-molded shoes) because of his/her diabetes. Prescriber Signature: _____ Prescriber Information Prescriber Name: NPI #: Phone #: Fax #: Address: PLEASE FAX THIS … chuchy 2 elenco