Medicare created the Therapeutic Shoe Bill to help patients with diabetes prevent foot problems. Medicare helps pay for up to 1 pair of qualifying shoes and 3 pair of inserts per year. Talk to your doctor to see if you qualify. It s easy: 1. Tear out this form and take it to the doctor who treats your diabetes. Your doctor will fill it out. 2. After your doctor fills it out, take it to your local provider who sells shoes. The provider will fit your new shoes, teach you how to wear them, and submit your forms for you. 3. Repeat at the same time next year. Statement Of Medical ecessity For Therapeutic Shoes & Inserts Patient s ame: HIC#: Address: City: State: Zip: Phone: DOB: I CERTIFY THAT ALL OF THE FOLLOWIG STATEMETS ARE TRUE: 1. THIS PATIET HAS DIABETES MELLITUS ICD CODE: m 250.00 m 250.01 m 250.02 m 250.03 m Other 3. I AM TREATIG THIS PATIET UDER A COMPREHESIVE PLA OF CARE FOR HIS/HER DIABETES. 2. THIS PATIET HAS OE OR MORE OF THE FOLLOWIG CODITIOS (Check all that apply): m History of partial or complete foot amputation m History of previous foot ulceration m History of pre-ulcerative callus m Peripheral neuropathy with history of callus formation m Foot deformity m Poor circulation 4. THIS PATIET EEDS SPECIAL DEPTH SHOES AD ISERTS BECAUSE OF HIS/HER DIABETES. #Units HCPCS CODE PRESCRIPTIO 1 2 A5500 Extra-Depth Shoes 2 4 6 A5512 Heat-Molded Insert 2 4 6 A5513 Custom Insert Physician s Signature: Date: Physician s Printed ame: PI#: Physician s Address: City: State: Zip: (continued on reverse side) LT0712PB www.orthofeet.com 2012 Orthofeet Inc. APPROVED FOR MEDICARE COVERAGE With, You re Free To Go Diabetic Shoes and Socks Catalog
Go with the Biomechanically Engineered Advantage. shoes provide you with ultimate comfort and protection because they are designed by engineers to work with your body. Go with the shoe with the heart in its sole. Your mobility, or freedom to move, is at the heart of every shoe design. It s why shoes are designed differently from other shoes. Every detail from their seamless lining to their ergonomic soles that help propel your foot forward is innovated for your comfort, protection and movement. So keep going... and look great doing it! With, you re free to go. Protective, Seamless Lining The lining of shoes does not have seams and is made from soft fabric and padded foam to eliminate irritation and soothe every step. Ergonomic Sole The trademarked Ergonomic-Stride design of soles helps propel your foot forward as it softens your step. Stretchable Uppers The lining of shoes features elastic uppers that stretch to the shape of your feet, easing pressure and enhancing comfort. Heat-Molded Diabetic Inserts ThermoFit inserts are molded with heat for an exact fit, providing unsurpassed comfort and protection for people with diabetes. Custom-Made Orthotics orthotics are made using an advanced computer system that carves the orthotic precisely to the impression of your foot. 2 www.orthofeet.com 3
You are geniuses of shoe design. Your shoes have changed my life. For years I searched for shoes that would fit my wide toe area and narrow heel. As soon as I tried on it was love at first fit. At age 60 plus I can out-walk everyone I know, even those a third my age. Vivian I. Medicare helps pay for certain diabetic shoes and inserts Medicare, Medicaid, or insurance may help pay for your shoes. For more information and easy directions, see the back page of this booklet. APPROVED FOR MEDICARE COVERAGE EW! Sandals: Free to be casual and cool. For Women and Men Heel strap allows you to adjust the grip around the heel Stretchable design gives you a customized fit at the forefoot Unique tie-less fastening system allows you to adjust the strap length on both sides of the shoe Lacing system enables you to adjust the fit throughout the entire forefoot Soft padded lining provides ultimate comfort and protection Tie-less Fastening System Women s 875 Women s 873 Men s 573 EW! Women s & Men s Sandals Women s Sizes: 5, 51/2-12 Widths: Medium, Wide, Extra-Wide Men s Sizes: 7, 7 1/2-11 1/2,12, 13, 14 Widths: Medium, Wide, Extra-Wide 4 www.orthofeet.com 5
855 856 Mary Janes: Free to buckle up and enjoy the ride. 859 851 853 Sport Sole Mesh Unique tie-less fastening system 854 864 allows you to adjust the strap from both sides of the shoe Modern, breathable mesh design Available in 6 fashionable colors 865 Models 854, 855, and 856 feature 861 862 876 6 a sport sole for added function = Available arrow www.orthofeet.com 7 Elastic Stylish design has an elastic upper for ultimate comfort Unique tie-less fastening system and heel strap for a custom fit 877 878 Traditional Elastic Upper Stretchable fit Classic styling always looks and feels great Model 865 also available in arrow Heel Strap Custom fit for comfort 879 Also see page 9 for Women s Stretchable Mary Janes. Women s shoes Sizes: 5, 51/2-12 Widths: Medium, Wide, Extra-Wide
Protective Lining Tie Shoes Combine modern styling with comfort Model 701 also available in Extra-Extra-Wide Tie-less Fastening System Innovative design combines laces with a strap, so shoes can be tied, or simply strapped on Women s Casual: Free to step out in style. Full Grain Leather 701 704 708 Suede Leather with Stretch 715 Stretchable with Strap Elastic uppers provide a comfortable, loose fit Eliminates pressure on diabetic feet with lesions, poor circulation or edema Also fits comfortably on feet with bunions or hammer toes Model 850 is made of suede leather and stretchable spandex Models 824 and 825 are made of synthetic materials and are also available in Extra-Extra-Wide Stretchable Mary Janes Mary Jane styling with all the therapeutic benefits of stretchable shoes Models 826, 827 and 828 also available in Extra-Extra-Wide Washable 850 824 825 827 828 Women s shoes Sizes: 5, 51/2-12 Widths: Medium, Wide, Extra-Wide Cushioning 826 Heel Supple 8 Leather 721 710 = Available Extra-Extra-Wide www.orthofeet.com 9
Strap Enclosures Classic styling and easy closure for all-day comfort Model 810 also available in Extra-Extra-Wide Women s Boots: Free to kick it up a notch. Strap Boots Extremely lightweight boots feel like you re wearing sneakers Offer excellent support Innovative design features an easy closure strap, so boots can be simply strapped on Extra foam padding prevents irritation, and offers a unique comfortable fit 810 830 820 881 Women s Dress: Free to have style and substance. Easy Slip-on Great-looking shoes have a wide opening for easy on and off Unique two-way fastening system allows you to adjust the strap length on both sides of the shoe for a perfect fit Models 812 and 814 feature a stylish 1½ heel Models 817 and 818 come with an additional longer strap Model 817 also available in arrow Fisherman Sandals: Free to breathe. Fisherman Sandals Extraordinary design combines comfort and protection with the comfort and breathability of a sandal Elastic design enhances the fit 871 874 10 www.orthofeet.com 11 = Available Extra-Extra-Wide = Available arrow 812 814 817 818 872 Women s shoes Sizes: 5, 51/2-12 Widths: Medium, Wide, Extra-Wide
One step fastening One step unfastening Women s Athletic Shoes: 916 Free to go the distance. Tie-less Fastening System Innovative design combines laces with a strap, so shoes can be tied, or simply strapped on Models 910 and 916 also available in Extra-Extra-Wide Model 916 also available in arrow Strap-and-Lace Biomechanically engineered to provide ultimate comfort and protection Models 921 and 920 also available in Extra-Extra-Wide Strap Enclosures 12 www.orthofeet.com 13 = Available arrow Adjustable Elastic Lace 910 921 920 = Available Extra-Extra-Wide Lace Slippers * : Free to explore your soft side. Slippers* Same trademarked Ergonomic Stride soles and body-forming design as shoes Extremely comfortable insoles can be removed and replaced with diabetic customized insoles Model S731 is available in Medium and Wide *ot approved for Medicare coverage. 950 951 940 941 S731 Adjustable Fit Women s shoes Sizes: 5, 51/2-12 Widths: Medium, Wide, Extra-Wide
Adjustable Lace Tie-less Fastening System Men s Athletic Shoes: Free to stay in the game. Innovative design combines laces with a strap, so shoes can be tied or simply strapped on Model 610 also available in Size 15 and Extra-Extra-Wide Strap-and-Lace Biomechanically engineered to provide ultimate comfort and protection 610 620 621 Athletic Strap Models 650 and 651 also available in arrow Athletic Lace 651 640 Lightweight, cushioned sole with trademarked Ergonomic Stride design helps propel feet forward Models 640 and 641 also available in arrow 650 641 Men s shoes Sizes: 7, 7 1/2-11 1/2,12, 13, 14 Widths: Medium, Wide, Extra-Wide 14 = Available Extra-Extra-Wide = Available arrow www.orthofeet.com 15
Easy Slip-on Innovative design combines slip-on styling with an adjustable strap for comfort Dress Lace Men s Dress: Free to step out in comfort. Classic styling can be dressed up or down Seam-free lining with extra foam padding provides ultimate comfort and protection 517 585 587 467 Strap Enclosures Easy on-and-off strap for non-binding comfort and protection Lightweight, cushioned sole with trademarked Ergonomic Stride design helps propel feet forward Model 510 also available in Size 15 and arrow and Extra-Extra-Wide 510 520 Men s shoes Sizes: 7, 7 1/2-11 1/2,12, 13, 14 Widths: Medium, Wide, Extra-Wide Easy Slip-on 465 540 16 www.orthofeet.com 17 = Available arrow = Available Extra-Extra-Wide
Tie-less Fastening System Innovative design combines laces with a strap, so shoes can be tied, or simply strapped on Tie-less Fastening System The ultimate solution for people who have trouble tying laces Unique fastening system allows you to adjust the strap length on both sides of the shoe for a perfect fit Men s Casual: Free to go places in life. 415 644 421 422 462 Casual Lace Fast lace shoes with therapeutic detailing maximize comfort from heel to toe Model 410 also available in Size 15 and arrow and Extra-Extra-Wide 420 440 410 Men s Boots: Free to be rugged and handsome. Boots Extremely lightweight boots feel like you re wearing sneakers Offer excellent support Model 481 is a lace boot. Model 581 is a double strap boot. Model 582 is an elastic strap-and-lace boot. 481 Men s shoes Sizes: 7, 7 1/2-11 1/2,12, 13, 14 Widths: Medium, Wide, Extra-Wide 461 18 www.orthofeet.com 19 = Available arrow = Available Extra-Extra-Wide 582 581
Men s Stretchable Shoes: Free to expand your horizons. Elastic uppers provide a comfortable, loose fit Eliminate pressure on diabetic feet with lesions, poor circulation or edema Also fit comfortably on feet with bunions or hammer toes Model 525 also available in Size 15 and arrow and Extra-Extra-Wide Men s Fisherman Sandals: Free to open up a little. Men s Fisherman Sandals Extraordinary design combines comfort and protection with the comfort and breathability of a sandal Elastic design enhances the fit 525 Washable 550 571 572 = Available arrow Men s Slippers * : Free to relax in style. Men s Slippers* Same trademarked Ergonomic Stride soles and body-forming design as shoes Extremely comfortable insoles can be removed and replaced with diabetic customized insoles Model S331 is available in Medium and Wide S331 *ot approved for Medicare coverage. Wide Opening, Adjustable Fit 20 www.orthofeet.com 21 = Available Extra-Extra-Wide Men s shoes Sizes: 7, 7 1/2-11 1/2,12, 13, 14 Widths: Medium, Wide, Extra-Wide
Loose, Wide Fit PRESCRIPTIO FOR THERAPEUTIC SHOES AD ISERTS White Sole Ventilated Mesh Smooth Toe Seam on-constricting Design Biosoft Bamboo Diabetic Socks: Start with a strong foundation. A very loose fit combined with super-stretch fabric helps maximize blood flow. Smooth Toe Seam Innovative design makes the inside of the sock virtually seam-free, giving you maximum protection against blisters and irritation. atural Anti-bacterial and Anti-odor Fabric Ideal for sensitive skin, bamboo fibers do not allow the spread of bacteria on the skin and work to eliminate odor. Anti-blister Protection Bamboo fibers are brushed in a unique process, making the inside of the sock extremely soft for minimal friction and extraordinary comfort and protection. Padded Sole Socks Loose knit design with super stretch soft terry padding with bamboo fibers Smooth Toe Seam White Sole Ventilated Mesh Available in S, M, L, XL Dress/Casual Socks Thin, light socks, ultra soft interior Smooth Toe Seam Available in S, M, L, XL Extra Roomy Fully Padded Socks Wide, ultra loose welt Soft terry padding with bamboo fibers All terry interior Available in S, M, L, XL Foot Warmers Micro fibers, thick and warm Available in M, L Size chart: S Women s 4-7 M Men s 6-8.5 Women s 7.5-10 L Men s 9-11.5 Women s 10.5-13 XL Men s 12-15 Available colors for all socks (except Foot Warmers) Patient s ame: HIC#: Address: City: State: Zip: Phone: DOB: Per statement of the certifying physician, the patient has one or more of the following conditions: m History of partial or complete m Peripheral neuropathy with foot amputation history of callus formation m History of previous foot ulceration m Foot deformity m History of pre-ulcerative callus m Poor circulation Inserts Prescribed: m Heat-Molded Insert m Custom Insert Shoes Prescribed: m Extra-Depth Shoes Physician s Signature: Date: Physician s Printed ame: PI# Physician s Address: City: State: Zip: Instructions: www.orthofeet.com 22 www.orthofeet.com 23 (continued on reverse side)