Forms

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• Please download and fill out our forms here. Once completed, you may send them to us at customerservice@sanluispodiatrygroup.com Thank you!

• San Luis Podiatry Group New Patient Information Forms

  Once you've requested an appointment with us, feel free to print this form, fill it out, and bring it with you to save time in our waiting room.

• Custom Functional Foot Orthotics: Financial information

  If custom orthotics are an indicated procedure for you, as determined by our evaluation, the following information covers our fee policy.

• Medical Records Release Authorization

  Authorization to release your medical records to another physician.

• DMV Application for Disabled Person Placard or Plates

  For temporary or permanent parking placards, travel parking placards, or disabled person license plates.

• Employee Claim for Disability Insurance Benefits (Sample)

  From the Sate of California Employment Development Department.

  Effective March 1, 2013, SDI claims can be filed electronically using SDI Online, or by ordering  the Claim for Disability Insurance Benefits, DE 2501 (10-16) Optical Character Recognition (OCR) form at http://www.edd.ca.gov/Forms/.

• Family and Medical Leave Act and California Family Rights Act

  FMLA/CFRA Policy and Procedures

• Employee Application for Family Care and Medical Leave

  This application is provided for employees to document their request for Family Care and Medical Leave (FML). Any request for FML leave for any purpose and its approval or denial must be properly documented.

  Effective March 1, 2013, SDI claims can be filed electronically using SDI Online, or by ordering  the Claim for Disability Insurance Benefits, DE 2501 (10-16) Optical Character Recognition (OCR) form at http://www.edd.ca.gov/Forms/.

• Certification of Health Care Provider for Employee

  The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because of a need for leave due to a serious health condition to submit a medical certification issued by the employee’s health care provider.

• Do you qualify for a Diabetic Shoe through Medicare?

  The information provided will help you verify whether or not you are eligible to receive Therapeutic Diabetic Extra Depth footwear through Medicare and other participating insurances. This program is designed to help reduce the incidence of foot ulcerations that could lead to foot amputations.

• Medicare's Therapeutic Shoe Bill

  According to the American Diabetes Association, there are approximately 16 million Americans with diabetes. Unfortunately, this number continues to grow. Twenty-five percent of persons with diabetes develop foot problems related to the disease. Recognizing this problem, Congress approved the Medicare Therapeutic Shoe Bill, helping thousands of persons with diabetes obtain protective footwear and inserts.

• Statement of Certifying Physician for Therapeutic Shoes

  Medicare requires that your primary care physician (doctor treating your diabetes) complete this form.

• Advance Beneficiary Notice of Noncoverage

  Medicare does not pay for everything, even some care that you or your health care provide have good reason to think you need.

• Statement Of Certifying Physician and Prescription

  To be completed by the physician monitoring the diabetic condition.

• FSCAN Screening Diabetics

  Please complete this form prior to your FSCAN Screening visit.

• FSCAN Diabetic Screening Waiver

  Please complete this form prior to your FSCAN Screening visit.

• Diabetes Foot Screen Form

  A variety of questions to help determine the nature and severity of issues due to diabetes.

• EDD Claim for Disability Insurance Benefits

  Standardized form from the State of California Employment Development Department