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CUSTOM DIABETIC ORTHOTIC ORDER FORM18772299652 ArchFitters 1625SEHoganRd,Suite Gresham,OR97080Store ID#:Clinician:Phone: M.I. FirstPoint NAME Shoe SizeWidthDate:LastTemplate #Quantity Ordered Male(3

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What is diabetic-custom-order-form-9-19-19?

The diabetic-custom-order-form-9-19-19 is a specialized form used to order diabetic medical supplies or medications customized to a patient's needs.

Who is required to file diabetic-custom-order-form-9-19-19?

Healthcare providers or patients needing diabetic supplies that require a prescription and customization must file the diabetic-custom-order-form-9-19-19.

How to fill out diabetic-custom-order-form-9-19-19?

To fill out the form, provide patient information, physician details, requested items, quantities, and any specific customization requirements.

What is the purpose of diabetic-custom-order-form-9-19-19?

The purpose of the form is to ensure that patients receive the proper diabetic supplies tailored to their specific medical needs.

What information must be reported on diabetic-custom-order-form-9-19-19?

Required information includes patient name, address, date of birth, physician name and NPI, item type, quantity, and any special instructions for customized orders.

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