Certificate of Medical Necessity (Shoes)
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Microcurrent Shoes
2200 N.E.2nd ave
Boca Raton, Florida 34431
Phone: 561-251-0332
Email: forms@microcurrentshoes.com
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**Physician Instructions:
Complete ALL check boxes under the two products needed |
Patient Phone: _________________________ DOB:______________________________
Patient Name: ________________________________ Medicare #__________________
Address:_________________________________________________________________
City State Zip
Statement of Certifying Physician & Prescription for:
Therapeutic Shoes and Inserts
1) This patient has diabetes mellitus: (please check one)
250.00 Type II controlled 250.01 Type I controlled
250.02 Type II uncontrolled 250.03 Type I uncontrolled
2) This patient has one or more of the following conditions: (please check all that apply)
History of partial or complete amputation of the foot
History of previous ulceraction Poor circulation
Peripheral neuropathy with evidence of callus formation
History of pre-ulcerative callus Foot Deformity
3) I am treating this patient under a comphrehensive plan of care for his/her diabetes, Arthritis or Raynaud's disease
4) This patient needs special shoes (extra-depth shoes) and/or inserts because of their diabetes
DX: Diabetes Mellitus (ICD-9 code 250.00 - 250.91)
RX: Extra-Depth Diabetic shoes and 3 pairs of heat molded multi-density inserts
Statement of Certifying Physician & Prescription for:
Ankle/Foot Gauntlet
1) This patient has Arthritis or Raynaud's Disease (please check one)
Arthritis Raynaud's Disease Diabetes
2) This patient has one or more of the following conditions: (please check all that apply)
PVD Poor Circulation Rheumatoid Arthritis Disuse Atrophy
Peripheral neuropathy Gout RSD Raynaud's Disease
3) I am treating this patient under a comphrehensive plan of care for his/her diabetes, Arthritis or Raynaud's disease
4) This patient needs the Ankle/Foot Gauntlet because of their condition
Rx: Ankle/Foot Gauntlet
Physician Name:____________________________ UPIN#________________________
Phone: ( ) __________-_______________ Fax: ( ) ________-_________________
Address:________________________________________________________________
City State Zip
Attending Physican Signature:_______________________ Date: ____/_____/_______
Original Signature Only - No Stamp
Diabetic Shoes Products Ordered:
One pair extra depth and three (3) pairs of inserts:____________
Product Code:________________ Mfg: ______Dr._Zen__
Shoe Type:
Lace____ Velcro____ Color____ Size____ Width____ Lycra____ Leather____
Men's_____ Women's___
Diabetes, Arthritis, & Raynaud's Disease Product
One each Ankle/Foot Gauntlet:
Left Foot Right Foot Bilateral
Product Code: 8*232 Mfg: __________________
Print out (CTRL P TO PRINT) and mail or fax form to
Microcurrent Shoes
2200 N.E.2nd ave
Boca Raton, Florida 34431
Phone: 561-251-0332
Email: forms@microcurrentshoes.com
FAX: 561-251-0332
