Statement of Certifying Physician for Therapeutic Footwear
PLEASE READ CAREFULLY
HAWLEY LANE SHOES
Diabetic Footwear Prescription Form
NOTE: For coverage by Medicare (and other insurance) this prescription must be
accompanied by a signed statement of certifying physician (SCP). THE SCP MUST
BE SIGNED BY AN M.D. OR D.O. MANAGING THE PATIENT’S SYSTEMIC DIABETIC
CONDITION.
Name: _______________________________ Phone: _________________
Patient’s Name: ___________________________ Date: ________________
I certify that all of the following statements are true:
Address: _______________________________________________________
1) This patient has one or more of the following conditions (check all that
apply):
___ a. History of partial or complete amputation of the foot
___ b. History of previous foot ulceration.
___ c. History of pre-ulcerative callus
___ d. Peripheral neuropathy with evidence of callus formation
___ e. Foot deformity
___ f. Poor circulation
City: _____________________ State: _________ Zip Code:______________
Diagnosis*: ____________________________
*ICD 10 Codes: E 10.10 – E 10.69 and / or E 11.00 – E 11.69
Check Prescribed Procedure:
□ Extra-Depth Shoes (A5500) including fitting
2) □ Direct-Mold Inserts (A5512) heat molded to patient’s foot
1)
*ICD 10 Codes: E 10.10 – E 10.69 and / or E 11.00 – E 11.69
2) I am treating this patient under a comprehensive plan of care for diabetes.
3) This patient needs special footwear (depth or custom molded footwear)
and/or inserts because of their diabetic condition.
# of pairs: 3 2 1 (average life per insert is 4 months)*
3)
Date of Birth: _________________ Diagnosis*: _____________________
□ Custom Inserts (A5513) made from patients foot model
4) This patient’s current medical record indicates management/treatment of
both diabetes and one of the secondary conditions listed above.
# of pairs: 3 2 1 (average life per insert is 4 months)*
□ Custom Molded Shoes (A5501) & a total of (3) pairs of custom inserts
5) □ Shoe Modifications – Specify __________________________
5) I certify that I have medical records that document one or more of the
above conditions.
*Medicare and other insurance carriers allow up to (3) pairs of diabetic inserts
per year. With each pair of shoes (3) inserts will be dispensed. On average,
each pair lasts about (4) months.
_________________________ X ______________________ ___/___/___
4)
_________________________ X ______________________ ___/___/___
Physician’s Name (Printed)
Physician’s Signature
Date*
*Delivery of shoes must be within (3) months of this date.
Physician’s Phone: _______________________________________________
Physician’s NPI #: ________________________________________________
Physician: Please keep a copy of this certification in patients chart for
future reference.
THIS FORM MUST BE SIGNED BY AN M.D. or a D.O. ONLY
Physician’s Name (Printed)
Physician’s Signature MD/DO
Date*
*Delivery of shoes must be within (3) months of this date.
Physician’s Phone: ___________________Physician’s NPI #:___________________
Physician’s Address: ___________________________________________________
Please Call Our Office for an Appointment
PHONE: 203-712-1341
HAWLEY LANE SHOES ◊ 862 Bridgeport Avenue, Shelton CT 06484
MEDICARE PATIENTS
If you are a diabetic with Medicare
Part B benefits and a Medicare
Supplement you may be entitled to
(1) pair of certain diabetic shoes and
(3) pair of diabetic inserts once each
calendar year at no cost to you.
In order to qualify, you must be
diabetic with at least one of the
following conditions:
◊ History of partial or complete
amputation of the foot
◊ History of previous foot ulceration
◊ History of pre-ulcerous callus
◊ Peripheral neuropathy with
evidence of callus formation
◊ Foot deformity
◊ Poor circulation
If you meet at least one of the above
qualifications, the DOCTOR
TREATING YOUR DIABETES must
complete the attached form
certifying your condition(s).
If you have not met your yearly
deductible you will be billed for the
portion of the deductible that
remains.
We invite you to visit our board
Certified Pedorthists and recommend
that you CALL FOR AN
APPOINTMENT before coming into
the store so that we can serve you
better.
About HAWLEY LANE SHOES
Hawley Lane Shoes has been owned
and operated for three generations and
has been in business for over 40 years.
The family patriarch, the late Jack
Smolensky, was among the first
Pedorthists to graduate from New York
University. His sincerity and enthusiasm
to provide exceptional customer service
and education about footwear and its
effects on one’s health, set him apart.
Today we strive to continue his
impeccable level of service in all our
stores.
The HAWLEY LANE SHOES Mission
Our mission at Hawley Lane Shoes is to
enhance people’s lives by increasing
awareness through education on proper
foot care and proper footwear. Our
Pedorthists and trained fit experts are
available to provide the perfect fit
through understanding the anatomy
and biomechanics of the foot.
DIRECTIONS
STAMFORD: Take the Merritt Pkwy.
South (CT15) to exit 35. Turn right on
High Ridge Road heading toward
downtown. Located about 3 miles
down on the left side across from Lord
& Taylor.
NORWALK: Take the Merritt Pkwy.
South (CT15) to exit 42. Turn right on
(CT57) Weston Rd. Stay right at fork
for (CT 57) which becomes Kings
Highway North. Take slight right onto
Post Rd. West (US1). Follow to plaza.
SHELTON: Take Route 8 North to Exit
11 (Huntington Rd.) Take left on
Huntington Rd. and a right on
Bridgeport Avenue. Go 0.9 miles to
Shelton Square on the right.
MEDICARE
PRESCRIPTION FORM
CALL FOR AN APPOINTMENT
SHELTON
Shelton Square
862 Bridgeport Avenue
203.712.1341
(fax) 203.712.1314
STAMFORD
Bull’s Head Plaza
73 High Ridge Road
203.327.7664
(fax) 203.327.7646
♦
NORWALK
Hawley Lane Shoes
499 Westport Avenue
203.847.9400
(fax) 203.845.0304