Refer Your Patients with Confidence

Everything you need to refer patients to our clinic for diabetic shoes, orthotics, and arthritis-friendly footwear.

Accepting Medicare & Most Insurances
Self-Pay Options
In-Clinic & In-Home Visits in most areas
Online Booking

Which Form Should You Use?

Choose the option that fits your role in patient care:
1. Generate a Foot Exam Document
This form is for primary care providers managing the patient’s diabetes who are ordering diabetic shoes and need to complete a diabetic foot exam that meets all insurance documentation requirements.


2. Attestation Form
This form is intended for providers who manage a patient’s diabetes but do not personally conduct the foot examination. It allows them to attest to and concur with the findings of another qualified provider, such as a podiatrist or diabetic shoe specialist. The purpose is to create a concise attestation note for inclusion in the treating provider’s SOAP note.


Once generated, copy and paste the note into the Assessment/Plan (or Plan) section of your SOAP note to meet insurance documentation requirements.

Provide Certification of Medical Necessity & Prescription

Please complete the combined Certification of Medical Necessity & Prescription form.

The CMN, prescription, and recent medical notes are required to confirm medical need and meet Medicare/insurance rules. Without them, we cannot provide diabetic shoes or related services.

You may either download it and return it to us via fax or email, or simply fill it out online using this link: intake.diabeticshoeclinic.com/cmn

Download Here

Submit Patient Information

Please fax or email your patient’s office notes related to their diabetes to (859) 545-4989 or [email protected]

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