To save time and enable us to properly help with your footwear needs please print, complete and bring the forms as described below to your appointment.

Several of these forms apply if you've been referred by a medical professional for footwear, compression stockings, diabetic shoes and/or orthotics for which you would like Althea's to bill your medical insurance provider. Others only apply if you do not need medical billing.

Review the list below to select the forms that apply to your situation.

If you do not need medical billing print, complete and provide the following forms at your initial footwear appointment: Althea's Policies and Privacy Forms Althea's Patient Contact

If you would like us to verify medical coverage for your service with Althea's please print, have your doctor complete the physician portion of the following forms. Complete your sections and provide the forms at your appointment: Althea's Patient Contact Compression Stockings Diabetes Questionnaire Diabetic Footwear Prescription and Medical Necessity Certificate Medicare Supplier Standards Patient Agreement

• Click "Download" below to open the appropriate form as listed above.NOTE: Clicking "view" instead of "Download" may cause the form to print improperly. Be sure you only print from the "Download" option.
  
• From Mozilla/Firefox browser a dialog box will open that states "open with" and "Adobe Reader" should be selected in the drop down. If you do not have Adobe Reader installed, click here to download it free from Adobe.
• From Internet Explorer chose "open". As long as you have Adobe Reader, the file will automatically open. If you do not have Adobe Reader installed, click here to download it free from Adobe.
• Once the file is open, print by selecting the printer icon in the upper left corner of the Adobe screen or by pressing  "Ctrl+P" from your keyboard.

If you have questions, please contact Althea's so we can help.