v5 © 12-2006

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

If check boxes can't be used, enter product info and QTY.

Also use this box for Client Name & Number if needed.

IT IS RECOMMENDED THAT YOU INCLUDE THE MANUFACTURER'S STOCK NUMBER FOR ALL OSTOMY ITEMS TO ENSURE PROPER IDENTIFICATION AND CODING :

text entry area
.

.

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

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

.
Make This Patient A Diary Billing ? YES. NO ( Look on the Healthcare Menu for more information )
Click to Submit ->