Before Shoe & Insert Visit

Before Your Shoe/Foot Orthotics Visit

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.
  • 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.

  • Privacy & Financial Policies
  • Medicare Supplier Standards English Spanish
  • Patient Bill of Rights
  • HIPAA 

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.
Lorem ipsum dolor sit amet, consectetur adipisicing elit,
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.