Diabetic Shoes Through The Medicare Therapeutic Shoe Bill

As a Medicare Patient you may qualify for one pair of diabetic shoes per calendar year through the Therapeutic Shoes for Diabetics Program. Please provide us with your information below.

Florida Pedorthics Intake Form

Today's Date*
MM slash DD slash YYYY
Your Full Name*
Name First and Last
Date of Birth*
Month
Day
Year
Phone*
Your email address
Name of Primary Insurance*
Name of Secondary Insurance if Applicable
Name of Physician Treating Diabetes*
First and Last Name
Please provide the name of your Podiatrist if you see one
First and Last Name
Have you had a diabetic foot exam within the last 6 month?*
- Yes
- No
PATIENT COMMUNICATION PREFERENCES*
- Select All
- I AGREE TO EMAIL COMMUNICATIONS
- I AGREE TO TEXT COMMUNICATIONS
- I AGREE TO VOICE COMMUNICATIONS
Attestation*
I attest that I have not received diabetic shoes and/or inserts through my insurance for the current calendar year. I understand that the Medicare Therapeutic Shoe Program guidelines are very stringent and that patients do not automatically qualify. The qualification process requires the cooperation of your doctors as medical necessity must be properly documented before any product is dispensed. You must have specific conditions with you feet in order to qualify, and not all patients will qualify.
- By clicking here I acknowledge the attestation.