Patient:_______________________________________________________________

Medicare #:__________________________________

I certify that all of the following statements are true:

1. This patient has diabetes mellitus-ICD-9 code: ________(250.0-250.91)
2. This patient has one or more of the following conditions (circle all that apply):

1. History of partial or complete amputation of the foot.
2. History of previous ulceration.
3. History of pre-ulcerative callus.
4. Peripheral neuropathy with evidence of callus formation.
5. Foot deformity.
6. Poor Circulation.

1. I am treating this patient under a comprehensive plan of care for his/her diabetes.
2. This patient needs special shoes and/or inserts because of his/her diabetes.

Physician Signature:__________________________________Date Signed:___________

Physician name (printed):______________________________ UPIN #______________

Physician address:_________________________________________________________

Physician telephone number:______________________________