WebPhysician Statement for Therapeutic Shoes: HCA-47: Provider Self Disclosure Form: HCA-48: Fraud Referral: HCA 49: DMERP Provider Prior Authorization Attestation: HCA-50: Manual Pricing Checklist: HCA-52: Physician Order for Incontinence Supplies Ages 4-20: HCA-52A: Adult Incontinence Supply Form Ages 21 and above HCA-60: Prior … WebThe doctor who treats your diabetes must certify your need for therapeutic shoes or inserts. A podiatrist (foot doctor) or other qualified doctor must prescribe the shoes or inserts, and you must get the shoes or inserts from one of these: A podiatrist An orthotist A prosthetist A pedorthist Another qualified individual

Statement Of Certifying Physician For Therapeutic Shoes

WebStatement of Certifying Physician for Therapeutic Shoes Patient Name: HIC #: I certify that all the following statements are true: 1. This patient has diabetes mellitus. 2. This patient has one or Fill & Sign Online, Print, Email, Fax, or Download Get Form Form Popularity statement of certifying physician for therapeutic shoes form Get Form eSign WebThe Statement of Certifying Physician must be signed and dated within three months (90 days) prior to the delivery of diabetic shoes and shoe inserts. Which date will count for … federal joint sealing calgary

Therapeutic Shoes for Persons with Diabetes …

WebCGS Medicare Webtherapeutic shoes and inserts when they are dispensed to the patient. Suppliers, including podiatrist-suppliers, must recognize that they must meet all DMEPOS supplier … WebI certify that all of the following statements are true: 1. This patient has diabetes mellitus. 2. This patient has one or more of the following conditions. (Circle all that apply): a) History … decorative wood moulding trim