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NY Foot Performance Center Diabetic Footwear Prescription Form 2014 free printable template

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DIABETIC FOOTWEAR PRESCRIPTION FORM Patient Name: ID # DOB: / / DX Indicate ICD9 Code: 2. (249.00 250.93 please include 2digit ending) Patient must have at least ONE of the following Chart notes must
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NY Foot Performance Center Diabetic Footwear Prescription Form Form Versions

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NY Foot Performance Center Diabetic Footwear Prescription Form 2016
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NY Foot Performance Center Diabetic Footwear Prescription Form 2014
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How to fill out NY Foot Performance Center Diabetic Footwear

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How to fill out NY Foot Performance Center Diabetic Footwear Prescription

01
Obtain a prescription pad from your healthcare provider.
02
Fill in the patient's personal information including name, date of birth, and insurance information.
03
Indicate the specific type of diabetic footwear being prescribed (e.g., custom insoles, therapeutic shoes).
04
Provide clinical justification for the prescription, such as the patient's diabetes diagnosis or any foot-related complications.
05
Sign and date the prescription.
06
Provide any additional instructions for the footwear provider (e.g., specific measurements, shoe size).
07
Send the completed prescription to the NY Foot Performance Center or provide it to the patient for them to take.

Who needs NY Foot Performance Center Diabetic Footwear Prescription?

01
Patients diagnosed with diabetes who have foot complications such as neuropathy, ulcers, or deformities.
02
Individuals requiring preventive footwear to avoid foot-related issues due to their diabetic condition.
03
Patients with a history of foot problems related to diabetes.
04
Individuals seeking custom or specialized footwear for comfort and support.
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The NY Foot Performance Center Diabetic Footwear Prescription is a formal document that healthcare providers use to order specialized footwear for patients with diabetes to prevent foot-related complications.
Healthcare providers, such as podiatrists, physicians, or certified diabetic educators, are required to file the NY Foot Performance Center Diabetic Footwear Prescription on behalf of patients diagnosed with diabetes.
To fill out the NY Foot Performance Center Diabetic Footwear Prescription, the healthcare provider must provide patient information, specify the type of diabetic footwear needed, and include relevant diagnostic codes and signatures.
The purpose of the NY Foot Performance Center Diabetic Footwear Prescription is to ensure that patients with diabetes receive appropriate preventive footwear to reduce the risk of foot injuries and complications.
The information that must be reported on the NY Foot Performance Center Diabetic Footwear Prescription includes the patient's name, diagnosis details, the specific type of footwear prescribed, measurements, and the healthcare provider's certification and signature.
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