1932 Boradway 7501 Custer Road West

Everett, WA 98201 Lakewood, WA 98499

Phone: (425) 303-0108 Phone: (253) 473-4311

FAX: (425) 303-2539 FAX: (253) 473-4408

www.Altheas.Net www.Altheas.Net

Services We Provide:

• Diabetic Footwear

• Orthopedic Footwear

• Custom Foot Orthotics

• Shoe Lifts for leg length issues

• Shoe Repair

• Resole Shoes

• Compression Stockings for legs, arms, hands

• Diabetic Socks

• We accept most Insurances

• Questions? Please call or email info@altheas.net

Page 4

1932 Boradway 7501 Custer Road West

Everett, WA 98201 Lakewood, WA 98499

Phone: (425) 303-0108 Phone: (253) 473-4311

FAX: (425) 303-2539 FAX: (253) 473-4408

www.Altheas.Net www.Altheas.Net

Getting Diabetic Shoes & Inserts is as easy as

One, Two, Three… PATIENT INSTRUCTIONS: .

One Make an appointment with your Doctor who manages your diabetes and ask for a

Diabetic Foot Examination.

Two Complete the top sections of page 2 and 3 with your Name, Date of Birth and phone

Number, then give this packet to the doctor during your Diabetic Foot Examination

Three If you have not heard from us within 1 week of your doctor’s appointment, please call us

to see if we have the paperwork from your doctor’s office and we can schedule an

evaluation.

PHYSCIAN INSTRUCTIONS:

One Complete the Prescription for Diabetic Shoes and Inserts (page 2), along with any

special instructions. If the patient is not diabetic, do not use these forms.

Two

Complete the (CMN) Certificate of Medical Necessity (page 3), confirming the patient

meets Medicare’s criteria – they have diabetes and one of the six qualifying conditions

listed on the Statement.

Three – (Medicare patients only)

Provide a copy of your Patient Notes – the sections showing 1) diagnosis of the

qualifying condition and 2) treatment of the patient’s diabetes.

Page 1

FOR MEDICARE PATIENTS:

FAX RX, CMN AND SUPPORTING CHART NOTES TO FAX # AT TOP OF PAGE

Althea's Footwear Solutions Althea's Footwear Solutions Althea's Footwear Solutions Althea's Footwear Solutions

1932 Broadway 7501 Custer Road West 1932 Broadway 7501 Custer Road West

Everett, WA. 98201 Lakewood, WA 98499 Everett, WA. 98201 Lakewood, WA 98499

Phone: (425) 303-0108 Phone: (253) 473-4311 Phone: (425) 303-0108 Phone: (253) 473-4311

Fax: (425) 303-2539 Fax: (253) 473-4408 Fax: (425) 303-2539 Fax: (253) 473-4408

www.altheas.net www.altheas.net www.altheas.net www.altheas.net

Patient Name: Patient Name:

Date of Birth: Phone: Date of Birth: Phone:

Diagnosis: I certify that the following statement is true:

Type II

Rx: A5500 1-Pair of Diabetic Extra Depth Shoes 1.) The patient listed above has Diabetes Mellitus: Type I Not Diabetic

A5513 Up to 3-Pair of Custom Diabetic Multi Density Inserts 2.) ICD-10 Diagnosis Code:

Additional Instructions: 3.) QUALIFYING CONDITIONS: I have diagnosed and am including my notes showing

that this patient has one or more of the following:

History of previous foot ulceration

History of pre-ulcerative callus

Peripheral neuropathy WITH evidence of callus formation (must have both)

Length of Need: Foot Deformity

Poor Foot Circulation

Prognosis: Good Fair Poor History of partial or complete amputation of the foot or toes

None of the above

Physician's Signature: Date: 4.) I am treating this patient under a comprehensive plan of care for Diabetis Mellitus.

5.) The patient needs extra depth shoes with multi density inserts because of diabetes.

Physician Name Printed: 6.) I certify that all of the conditions checked above are in my doctor's notes

within the past 6 months.

Practice Address

MD/DO Signature: Date:

Physican Phone: Fax:

MD/DO Name Printed:

Physician's NPI: Office Phone: Office Fax:

Prescription for Diabetic Shoes and/or Orthotic Inserts Certificate of Medical Necessity for Therapeutic Shoes

Page 2 Page 3

FOR MEDICARE PATIENTS: FOR MEDICARE PATIENTS:

FAX THIS PAGE W/ SUPPORTING CHART NOTES TO # AT TOP OF PAGE FAX THIS PAGE W/ SUPPORTING CHART NOTES TO # AT TOP OF PAGE