Physician Order Form – Synergy DMEPOS

Supplies Needed:

Extra Depth Therapeutic Shoes (A5500) Quantity - 2 (1 pair) Custom Inserts (A5514) Quantity - 6 (3 pairs) Toe Filler for Partial Foot Amputees (L5000) Quantity - 1 Heat Molded Inserts (A5512) Quantity - 6 (3 pairs)

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;

2) This Patient has one or more of the following conditions:

Poor Circulation 187.2 History of Pre-Ulcerative Callus: L84 History of Foot Ulceration Z86:31

Hammer Toes

(RT)M20.41 (LT)M20.42

Heel spurs

(RT)M77.31 (LT)M77.32

Bunions

(RT)M20.11 (LT)M20.12

Other Type of Foot Deformity

Foot

(RT Foot)Z89.431 (LT Foot)Z89.432

Great Toe

(RT Foot)Z89.411 (LT Foot)Z89.412

Ankle

(RT Foot)Z89.441 (LT Foot)Z89.442

Other Toes

(RT Foot)Z89.421 (LT Foot)Z89.422

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.

Statement of Certifying Physician/Order Form

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