Take this form to your MD or DO, have him filll it out and give you a copy of your last exam notes, which must state the condition he/she checks off on the form.  ie: "Callus formation", "Diminished Pulses in Feet", "History of pre-ulcerative callus or foot ulceration", "Bunion" etc, or "History of partial foot amputation.

The notes must contain one of these conditions or you can not get shoes.

Medicare Form

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