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*
Your Full Name*
Name First and Last
Date of Birth*
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
Did your doctor provide you with a prescription?
- Yes
- No
PATIENT COMMUNICATION PREFERENCES*
- Select All
- I AGREE TO EMAIL COMMUNICATIONS
- I AGREE TO VOICE COMMUNICATIONS
PLEASE PROVIDE ANY OTHER PERTINENT INFORMATION. EXAMPLES INCLUDE GOOD FAX NUMBERS FOR YOUR DOCTORS AND ANY GOOD POINTS OF CONTACT IN THEIR OFFICE.
IF YOU’VE HAD A FOOT EXAM AND WERE GIVEN A PRESCRIPTION, PLEASE CONTACT THE DOCTOR WHO WROTE YOUR PRESCRIPTION AND HAVE THE OFFICE SEND YOUR FOOT EXAM TO US. A FOOT EXAM IS THE MOST IMPORTANT PART OF THE PROCESS. NOT ALL PATIENTS QUALIFY. QUALIFICATION IS BASED ON YOUR FOOT EXAM FINDINGS.