1. Diabetic Shoes/Inserts
Practice Protocol

2. Physician Practice Initial Patient Contact
Foot Examination for Prescription Diabetic Shoes
Patient Phones Office
Schedule appointment for Diabetic Foot Exam for Shoes
Patient is in office for a current complaint
Offer to reschedule patient for foot exam or, time permitting, complete foot examination during visit

3. Foot Examination Complete foot examination
Include findings and recommendation in clinical notes
Complete prescription for diabetic shoes and inserts
Advise patient that prescription and supporting paperwork will be forwarded to shoe provider

4. Referral Fax: 855-376-4049 Patient Demographics Prescription
Clinical Notes

5. Patient Contact Sports and Wellness will:
Contact patient upon receipt of request and patient will be educated on program process
Verify patient benefits
Submit Certifying Statement and Detailed Written Order to PCP within 48 hours of receipt of referral
Once Certifying Statement and DWO are received, contact patient for appointment
Patient and Physician will be updated throughout the process

6. Diabetic Shoe Selection Exam
Program process will be again discussed with patient in detail
Patient will be assessed, shoes and inserts will be selected
If custom inserts prescribed, a patient impression will be made
Heat Moldable Inserts and Shoes generally take 1 week to arrive
Custom Inserts/Shoes generally take 3-4 weeks

7. Dispensing
Upon shoe and insert arrival, patient will be contacted and scheduled for return to office for fitting
Shoes/Inserts are fit and assessed for proper fit
Patient is referred back to Prescribing Physician for follow- up

8. Post Script
Evaluation notes will be forwarded to Prescribing Physician after dispensing appointment
Follow up will be performed with patient 2-3 days after dispense, by phone
In office follow up will be scheduled for 2 weeks
If any complications or patient complaint arises, Prescribing Physician will updated accordingly