v6 © 07-2008

THERAPEUTIC DIABETIC SHOES

Use your SHIFT LOCK * one patient

per submission

THIS APPLICATION IS USED FOR AN EXISTING PATIENT PROCESSING ONLY.
PROVIDER INFORMATION
Your Integrated Client Number or your name
IMPORTANT:
PLEASE - At Least Once Per Session of Claim Entry :
YOUR EMAIL ADDRESS:
PRODUCT INFORMATION

.
 .      

.Patient Name

(last name first name mi)

.Date of Delivery

.(MM - DD - YY)

.      

.
 description stock number qty charge

.
 For diabetics only, fitting (including follow up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate
multi-density insert(s), per shoe		 qty $
For diabetics only, fitting (including follow up), custom preparation and supply of shoe molded from cast(s) of patient's foot (custom-molded shoe), per shoe qty $
For diabetics only, multiple density insert(s), per shoe qty $
For diabetics only, modification (including fitting) of off-the-shelf depth- inlay shoe or custom-molded shoe with roller or rigid rocker bottom, per
shoe		 qty $
For diabetics only, modification (including fitting) of off-the-shelf depth- inlay shoe or custom-molded shoe with wedge(s), per shoe qty $
For diabetics only, modification (including fitting) of off-the-shelf depth- inlay shoe or custom-molded shoe with metatarsal bar, per shoe qty $
For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with off-set heel(s), per shoe qty $
For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe qty $
For diabetics only, deluxe feature of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe qty $

Only Non-Participating Medicare Providers or claims for other than Medicare patients may use the providers price

.

.ARE YOU ACCEPTING ASSIGNMENT ? If this claim is for a Medicare Claim *

.YES NO * ( only non participating Medicare providers may check NO )

.

Message or Notes

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