Patient Name:_____________________________________________________

Patient Telephone :___________________Patient Date of Birth:_____________

HIC #:___________________________________________________________

I certify that all of the following are true:

1. This is a patient with diabetes mellitus — ICD-9 Code:____________________

(ICD-9 diagnosis codes 250.00-250.91)

2. This patient has one or more of the following conditions: (check all that apply)

• History of partial or complete amputation of the foot
• History of previous foot ulceration
• History of pre-ulcerative callus
• Peripheral neuropathy with evidence of callus formation
• Foot deformity
• Poor circulation

3. I am treating this patient under a comprehensive plan of care for his or her diabetes.

4. This patient needs special shoes (depth or custom-molded shoes) and/or inserts because of his/her diabetes.

Certifying Physician Information

Signature:________________________________________________________

Physician Name (Print):_____________________________________________

Physician address:_________________________________________________

________________________________________________________________

Physician UPIN #:__________________________________________________