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Sample Prescription Form(Completed by a Podiatrist or other qualified physician knowledgeable in the fitting of therapeutic shoes and inserts.)Patient’s Name:________________________________Date________________ Address:_________________________________________________________ City, State, Zip:____________________________________________________ Patient Telephone :___________________Patient Date of Birth:_____________ Patient’s Medicare ID #:_____________________________________________ DX:
RX:
Orthosis
Shoe Modification
Instructions:_______________________________________________________ ________________________________________________________________ Prescribing Physician Information Signature:________________________________________________________ Name (Print):______________________________Phone;__________________ DEA #:___________________________________________________________ Medicare UPIN#___________________________________________________ Medicare Provider #________________________________________________ |