NY Foot Performance Center Diabetic Footwear Prescription Form 2016-2025 free printable template
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DIABETIC FOOTWEAR PRESCRIPTION FORM Patient Name: ID # DOB: / / DX Indicate ICD10 Code: E. (E08.9 E10.8) INSURANCE REQUIRES ICD10 CODES TO BE INCLUDED IN PATIENT RECORD Patient must have at least
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How to fill out diabetic footwear prescription form
How to fill out NY Foot Performance Center Diabetic Footwear Prescription
01
Obtain the prescription form from the NY Foot Performance Center.
02
Fill out the patient's personal information, including name, address, and contact details.
03
Indicate the patient's medical history, specifically related to diabetes and foot issues.
04
Specify the type of diabetic footwear required (e.g., custom-made, off-the-shelf).
05
Include any specific features needed for the footwear such as extra depth, adjustability, or arch support.
06
Ensure that the prescriber signs and dates the form.
07
Submit the completed prescription to the NY Foot Performance Center, along with any additional required documentation.
Who needs NY Foot Performance Center Diabetic Footwear Prescription?
01
Individuals diagnosed with diabetes who are at risk for foot complications.
02
Patients experiencing neuropathy or other foot-related issues due to diabetes.
03
People seeking preventive footwear to avoid ulcers or foot injuries.
04
Those recommended by a healthcare provider or specialist for diabetic footwear.
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What is NY Foot Performance Center Diabetic Footwear Prescription?
The NY Foot Performance Center Diabetic Footwear Prescription is a formal document issued by healthcare providers that specifies the need for specialized footwear for patients with diabetes. These shoes are designed to reduce the risk of foot injuries and complications.
Who is required to file NY Foot Performance Center Diabetic Footwear Prescription?
Healthcare professionals, such as doctors or podiatrists, who are treating diabetic patients are required to file the NY Foot Performance Center Diabetic Footwear Prescription to ensure their patients receive the appropriate footwear.
How to fill out NY Foot Performance Center Diabetic Footwear Prescription?
To fill out the NY Foot Performance Center Diabetic Footwear Prescription, the healthcare provider must complete the patient’s information, specify the type of footwear needed, indicate any special features required, and sign the document to validate it.
What is the purpose of NY Foot Performance Center Diabetic Footwear Prescription?
The purpose of the NY Foot Performance Center Diabetic Footwear Prescription is to provide a written directive for obtaining medically necessary footwear, which helps prevent complications associated with diabetes, such as ulcers and infections.
What information must be reported on NY Foot Performance Center Diabetic Footwear Prescription?
The NY Foot Performance Center Diabetic Footwear Prescription must report the patient's personal information, specific diabetic condition, type of footwear recommended, any modifications needed, and the prescribing healthcare provider's details.
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