1 – Detailed prescription

Must indicate diagnosis

Must indicate item(s) being prescribed

Must have legible physician signature

Must be dated within the past 6 months

2 – Statement of certified physician for therapeutic shoes (CMN) certified medical necessity

Must be completed by physician who treats the diabetes (not PA or nurse)

Must indicate all ailments that apply

Must have a legible physician signature and must be dated within the past 6 months

3 – Physician progress notes

Must be completed by the physician who treats your diabetes

Must support the information on the statement of Certify Physician for Therapeutic shoes (CMN)