A prescription is required for diabetic therapeutic shoes and custom inserts, as well as any device that we fabricate for you. The prescription must come from your doctor, we cannot write one for you. If you do not already have a prescription, our office can provide you with the details you will need to bring to your physician to obtain a prescription.
Forms and Insurance Requirements
We understand that the insurance process can be complicated, and we are here to help you. Forms and information needed for your shoe/foot orthotic visit are listed below. If you have any questions, please call us at 413-785-4047.
Required forms and medical documentation for your first visit:
- Required for all patients: Consent form
If possible, please print, complete, and bring this form to your first visit. Copies are also available in our office.
- Medical release form This is necessary for all forms of insurance. Copies are also available in our office.
- Required for all patients: A prescription for diabetic shoes and/or custom inserts
- Required for Medicare patients: An MD OR DO physician’s notes and Medical Release form
- Please have your medical records faxed to our office at 413-785-4048 ATTN: Medical Records.
- For your convenience, common medical release forms based on referring/treating treating physicians are listed below. Please select and complete the appropriate form.
Baystate Medical Record Release English Español
Cooley Dickinson Medical Record Release English Español
Hartford Hospital Medical Record Release English Español
Holyoke Medical Center Medical Record Release English Español
Mercy Medical Record Release English Español
Mt. Sinai & St. Francis Medical Record Release English
Riverbend Medical Record Release English
If you do not see your referring facility in the list above, please complete our standard medical release form.
P&O Solutions Medical Record Release English Español
- Required for MassHealth Primary Care Clinician Plans (PPC): A referral from your primary care physician
Please have your doctor’s office submit a referral through the MassHealth provider portal. Our NPI# is 1558376913.
- For all patients, please consider sharing relevant medical records. Notes from your primary care doctor, podiatrist, or other medical providers will assist our pedorthist in understanding your needs, recommending the best shoe/foot orthotic for you, and providing continuity of care.
The following forms are for your information. They DO NOT need to be completed or signed.
Insurance Requirements for Diabetic Footwear By Plan Type
For patients with:
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If you have a MassHealth plan that covers orthotic and prosthetic services, you may be eligible for one pair of diabetic shoes and three pairs of custom heat molded inserts per year. In order to qualify, the following is required:
- Both the medical documentation AND the prescription must come from the primary care physician or endocrinologist with the credentials of MD or DO. Unlike Medicare, another professional CANNOT write the prescription.
- A copy of this form completed by the same MD or DO physician that writes your prescription: MassHealth CMN pdf
*Please remember: MassHealth Primary Care Clinician Plans (PCC) require a referral from your primary care physician. Please have your doctor’s office submit a referral through the MassHealth provider portal. Our NPI# is 1558376913.
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sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad
minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea
commodo consequat.
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sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad
minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea
commodo consequat.