Patient Information

For your convenience we have supplied most of the documents that we will need during your first visit. Please let us know if you have any questions and we will be more that happy to assist you with any of these forms.

If you decide to fax these documents please fax with doctor prescription, photo id and insurance card if possible. To be certain that all documents have been received follow up with a phone call to our office.

Office: 817-336-8293
Fax: 817-336-9017

HIPAA Forms

*HIPAA Forms are required for all ProsthetiCare patients.
Please have these copies ready on your first visit to ProsthetiCare. If it is easier you can fax this information directly to us at 817-339-9017.

Diabetic Verification Forms

*Please Note All Forms Are Needed Prior to Setting An Appointment

Diabetic Footwear

The proper footwear is essential for people with diabetes as the disease can cause circulation problems, infection, foot ulcers and nerve damage. Diabetic footwear is designed to protect your feet while providing the proper support. Our line of footwear is available in many styles and colors. We will measure your feet before each purchase to ensure that shoes you are buying fit well and prevent many foot related problems.

**ALL PATIENTS – PLEASE READ**

Medicare and All Private Insurance companies have implemented significant changes and requirements to the diabetic program. In order to fulfill the requirements of these changes, certain documentation is needed to proceed with your care.

PATIENT RESPONSIBILITY

1- Please obtain a copy of your diabetic doctor’s notes from within the last 6 months.
The easiest way to receive your notes is to contact your diabetic doctor’s nurse or medical records department and request the information. Insurance requires medical records from your diabetic doctor documenting the condition of your feet. Your doctor has to have the title of MD or DO. If you have not had your feet examined by the doctor treating you for diabetes you need to make an appointment before we can see you. Your doctor also needs to document in your notes that you qualify for shoes and inserts. Insurance does not accept these qualifying notes from a nurse practitioner (NP), physician assistant (PA) or podiatrist (DPM). ProsthetiCare will verify that the appointment occurred within the last 6 months and that the Insurance required information is contained in the notes. If the notes do not meet the requirements, ProsthetiCare will suggest that you see your doctor again so that the required documentation can be included in the new visit notes.

2- Please obtain a signed copy of the Diabetic Verification Form [form attached below]
A Diabetic Verification Form must be signed and completed by the MD or DO who is managing your diabetes. This form includes the information that is required in the chart notes. You can give this form to your physician’s office to be completed and signed.

3- Please obtain a signed copy of the Prescription for Therapeutic Footwear [obtain from doctor’s office]
This Prescription for Therapeutic Footwear can be signed by your diabetic doctor or by another clinician who is managing the condition of your feet. Your Insurance allows this form to be signed by an MD, DO, podiatrist (DPM), nurse practitioner (NP), physician assistant (PA) or certified nurse practitioner (CNP).

Please have the copy of your notes and the completed forms forwarded to ProsthetiCare. You can request to have the information faxed to ProsthetiCare at 817-336-9017 from your doctor’s offices. You can also obtain the notes and signed forms and mail them to ProsthetiCare or drop them off with the ProsthetiCare staff.

Please print out BOTH Diabetic Information Form & Diabetic Verification Form and present them both together to your doctor.