Orders | Footway Orthopedics

The DPM has evaluated this patient's medical condition and determined that the patient needs therapeutic depth inlay shoes and inserts.

Authorized by DPM

Patient Information

First Name

Last Name

Gender

Male

Female

LGBTQ

DOB

Phone

Shoe Size

Shoe Width

Measurement Device

Brannock

Ritz

Primary Choice

Velcro

Shoelace

Shoe Primary Choice / Color

Secondary Choice

Velcro

Shoelace

Shoe Secondary Choice / Color

Special Instructions

Please enter the accomodations specifications (if any) in the Special instructions…

Ultra Thin

1/8" Pink Plastazote Top Cover
1/4" Grey Plastazote Shell
Heat Molded to Cast

Pre-Fabricated

Dual Density Inserts
Heat Moldable
3 Pairs

L5000

1/8" Pink Plastazote Top Cover
1/2" EVA Shell
1 Insert Per
Heat Molded to Cast

Approved Services Information

A55OO - Extra Depth Diabetic Shoes - 1 pair, unless otherwise noted.

A5512 - Prefabricated Heat Molded Inserts - 3 pairs, unless otherwise noted.

A5513/A5514 - Custom Inserts - 3 pairs, unless otherwise noted.

L5000 - Toe Filler - Partial Foot, Shoe Insert with Longitudinal Arch.

DIAGNOSIS CODES - Section A must be complete to validate prescription. Complete section B if applicable.

Section A — Primary Diagnosis Diabetes Mellitus

Section B — Specified Diagnosis

MD/DO further determine that the patient has one or more of the following conditions:

Foot Deformities

History of partial or complete amputation of the foot/toe(s)

Current or History of pre-ulcerative callus

Poor circulation

ATTENTION: Please specify the size and quantity of the diabetic shoes and prefabricated heat molded inserts in your progress notes…

ATTENTION: Please specify the size and quantity of the diabetic shoes and custom inserts, along with the scanner technology used to cast the patient in your progress notes…

Medicare Compliance Order

PCP/DO Information

PCP | Endocrinologist Information

Patient Information

Ultra Thin

Pre-Fabricated

L5000

Approved Services Information

Section A — Primary Diagnosis Diabetes Mellitus

Type I

Type II

Section B — Specified Diagnosis