Therapeutic Shoes & Compression Stockings

Please complete the form below to request therapeutic footwear or compression garments. Accurate measurements and medical justification are essential for CMS compliance.

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Patient Name *

Date of Birth (DD/MM/YYYY) *

Prescribing Physician Name *

Medical Condition Indicating Need *

Type of Item Requested

• Therapeutic Shoes
• Compression Stockings
• Both

Patient Date Justification

Measurement Data (if applicable)

exm: ankle, calf, foot length, etc.

Medical Necessity Justification *

Submit