Healthcare Provider Forms

Before you fax: provider checklist

Please send all three items. Complete every applicable field; use “N/A” where appropriate rather than leaving fields blank.

• ☐ Statement of Certifying Physician
  Complete the patient information, diabetes certification, qualifying foot condition, and required physician information. Include the certifying physician’s signature and date.
• ☐ Standard Written Order (SWO)
  Complete the patient information, applicable diagnoses, footwear and insert selections, and ordering practitioner information, including NPI. Include the ordering practitioner’s signature and date.
• ☐ Supporting doctor’s office visit notes
  Include dated, signed or authenticated notes documenting diabetes management and the qualifying foot condition that supports the order.
• ☐ Final review
  Confirm patient identifiers match across the documents, every required field is complete, and all required signatures and dates are present.

Fax the completed packet and notes to (864) 393-5396.

Insurance and payment options

• All Blue Cross Blue Shield plans
• Humana Medicare and Medicaid plans
• UnitedHealthcare
• Medicare
• Medicaid
• HSA/FSA payment options

Coverage, network participation, prior authorization, and required documentation depend on the patient’s specific plan. CAIRS verifies benefits before proceeding. HSA/FSA eligibility depends on the account’s rules.