Form needed

At one time I thought I saw a form that you can have a patient sign stating they haven’t received any shoes or foot orthotics within the calendar year from another provider. If they sign it and then later find out that they have already used there allotment with some one else, then you can have them pay for it when Medicare denies your claim. We just had this happen. The patient got shoes and inserts somewhere else then got all the paper work and came and had us provide shoes and inserts. Now Medicare is asking for the money back. Hopefully someone can provide me with a link to this form.
Thanks for your help.

Ed Hicks, C.Ped, CO
University of VA
Prosthetics & Orthotics

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