Diabetes


	YOU CAN CHOOSE where to receive your Therapeutic Shoes for Persons with Diabetes Why not choose the best protection you can get? It starts with a great fitting shoe that you'll enjoy wearing. Then we create custom comfort for you with three pairs of custom insoles that we make ourselves, using materials and custom attention to the details of your anatomy in order to provide the very best protection we can. It's well above the Medicare minimum standard - and at no extra cost to the patient. If you have medical insurance and are diagnosed with diabetes and foot complications, you may have coverage for therapeutic footwear with little or no out-of-pocket or up-front cost. To get started, fill out the form below or call 617-787-8780. Get the Forms Watch a 30-second commercial Is there a diagnosis of Diabetes? Yes No Have you worn therapeutic shoes before? Yes No What type of shoes do you wear? off-the-shelf custom slippers or sandals none of the above Do you have difficulty with comfortable shoe fitting? Yes No If "YES, what seems to be the problem? Optional: Do you have one or more of the following conditions? Poor circulation Peripheral Neuropathy Foot deformity History of pre-ulcerative calluses History of previous foot ulcerations History of partial or complete amputation of the foot Which location is more convenient for you? Brighton Woburn Whatever is faster Medical Insurance Medicare + secondary insurance Medicare + Mass Health Medicare + no secondary insurance Medicare Advantage Plan: Blue Cross Blue Shield Primary Medicare Advantage Plan: Harvard Pilgrim Medicare Advantage Plan: Tufts Medicare Preferred Mass Health Alternative: Senior Whole Health Mass Health Alternative: Commonwealth Care Alliance If Medicare, there are three forms required in addition to the prescription. Would you like the information mailed or emailed to you? Do you have a prescription yet? (You'll need one) About the prescription ... Is the prescription dated two months ago or less? What is the name of the doctor who wrote it? About the doctor who manages your diabetes What is his/her name? Have you seen the doctor within the past six months? Do you have a signed "Statement of Certifying Physician" from him/her? Patient Name First Name Last Name Contact Name First Name Last Name Relationship to Patient Address City State Zip Telephone Number E-Mail Address How did you heard of us? Is there anything else we should know about you? 99999 characters remaining Enter the code shown:


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