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Diabetic Shoes and Supplies are covered by Medicare at little to no cost if you qualify. We can help you qualify today by calling us at 1-800-844-1146.

* Required information

*First Name:
*Last Name:
*Telephone Number:
*Best Time to Call?    AM    PM
Time Zone:
Address:
Suite/Apt#:
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State:
Zip:
E-mail Address:
Fax:
Date of Birth:
Medicare Number
(if Applicable):


What is your Gender?


Do you have Diabetes?
Yes No

How many times a day do you test your blood?


Do you inject insulin?
Yes No
Enter any other information or questions here:

Primary Insurance Carrier:
Plan Number:
Group Number:
Insurance Phone Number:

Secondary Insurance Carrier:

Plan Number:
Group Number:
Insurance Phone Number:

Doctor Name:
City:
State:
Zip:
Telephone Number:
Fax:


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Will Medicare pay for my diabetic supplies?
Find out what Medicare pays for!
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