Statement of Certifying Physician/Order Form

A PDF version of this form can be downloaded here and sent to info@www.synergydmepos.com.

Length of Time Needed - Length of Time in Months: 1 pair per year
The Patient Listed above has Diabetes Mellitus with the Following ICD-10 Diagnosis Code:
Physician Information
I certify that all the Following Statement are True:
1) This Patient has Diabetes Mellitus;
3) I am treating this patient under a comprehensive plan of care for his/her Diabetes.
4) This patient needs special shoes (depth or custom-molded shoes) because his/her diabetes.
CERTIFYING PHYSICIAN (Must be MD or DO, PECOS Enrolled)
I certify that I am treating this patient under a comprehensive plan of care for his/her diabetes. I am in agreement with the medical records prescribing physician for coverage criteria, and I have obtained, signed and dated the foot examination completed by the prescribing physician. I certify that I have thoroughly documented the patient's medical necessity for products ordered and will provide the supplying DME with all required supporting documentation.