9131 College Parkway, Fort Myers,Florida (in the Neighborhood Walmart Center) Hours: Mon thru Sat 9:30 am to 5:00 pm 239-481-3404
Physicians Forms & Information...
The following information will be helpful in expediting services for certain patients. This information is provided as a service by Shoe Boat, Inc. but should not be relied upon as complete. Additional forms or information may be required. Guidelines are subject to change.
Documentation required by Medicare for Diabetic Footwear
The following documentation is required from the Physician…
Statement of Certifying Physician
MD/DO signed, ICD-9 code (250.00 – 250-91) check box of at least one factor(s) and dated within 3 months of dispensing shoes/inserts.
Physician Chart Notes on Qualifying Condition
Copy of Chart Notes from treating physician’s (MD/DO) current medical records document the patient is being treated for Diabetes Mellitus and has qualifying risk factor(s). Chart notes must be legible, dated within 6 months of dispensing shoes/inserts.
Description of items to be dispensed with diagnosis code (250.00 – 250-91). Signed and dated within 3 months of dispensing shoes/inserts.
You may find a lot of additional helpful information at the