Medicare approved diabetic shoes - Stylish Diabetic Shoes

Do I qualify for diabetic shoes?
You may be eligible for diabetic shoes - at no cost to you! Enter your information in the form below to find out if you qualify for diabetic shoe coverage. Medicare or your insurance provider may cover the cost of one pair of diabetic shoes and three pairs of custom or heat molded insoles per calendar year. Find out if you qualify now!

Personel Information

First Name				Last Name
Address				City
State				Zip
Date of Birth				Sex
Email Address				Phone #	( ) -

Medicare and Insurance Information

Is Medicare Your Primary Insurance?

Medicare #

Supplementary/Secondary Insurance Information

Name of Insurance Company?
Phone # (on back of insurance card)	( ) -
Policy Number / Member Id

Primary Physician Information (M.D. or D.O. only No Podiatrist Please)

First Name				Last Name
Address				City
State				Zip
Phone	( ) -			Fax	( ) -

Confirm & Submit Application

By submitting this information, I authorize NoCostShoes.com/Quantum Medical Supply Inc., its affiliates, subsidiaries, or parent company to contact me by phone or email. Please be assured that we value and protect your privacy. Remember, there is no purchase necessary to see if you qualify.