Rights Responsibilities and Sales Agreement

Shoe Certification

I understand that Medicare will only cover one pair of diabetic shoes each calendar year.

  • I have not received diabetic shoes from any other Medicare or insurance supplier this year, nor will I accept them from any other company at another time this year.
  • I also understand that if I request, or accept more than one pair in a calendar year, I will be held liable for the full cost of the second order, including the inserts.

Shoe/Insert Break-in Schedule

I acknowledge receiving instructions and agree to follow the Shoe Break-in schedule listed below.

  • I understand that it is recommended that I check my feet two to three times per day.
  • If I see anything that looks different than normal or out of the ordinarythat may result in scratches, blisters, cuts, etc. I will stop wearing the shoes and inserts and discontinue use immediately.
  • I will not hold the diabetic shoe supplier, company, or fitter liable in anyway whatsoever for any personal injury or property damage that the shoes or inserts may cause.

Shoe Wearing Time

Day 1-3 1 hour each AM + PM

Day 4-62 hours each AM + PM

Day 7-93 hours each AM + PM

Day 10-124 hours each AM + PM

Inserts – Custom & Pre-Fab

IMPORTANT: Remove the original shoe sock liner inserts and replace them with either the custom or

pre-fab inserts. I acknowledge receiving instructions and agree to follow the scheduled dates listedto change the inserts inmy Therapeutic Diabetic Shoes.

Change Inserts (4 months) ______Change Inserts (8 months) ______

(mm/dd/yy) (mm/dd/yy)

Return Policy & Equipment Warranty

Returnshoes will be accepted within 30 days from the delivery date. Shoe re-orders or refunds will be issued per patient request. IMPORTANT: Shoes MUST be returned in re-salable condition, in their original box. Dirty or used-looking shoes will not be accepted. Please wear shoes indoors on carpet during break-in period. Returns after 30 days and Custom Order Items are subject to fees. Under normal wear conditions, the DME will repair or replace, free of charge, Medicare-covered shoes within 6 months from delivery date.

Instruction to Patient-Return/Demonstration Acknowledgement

I acknowledge receiving instructions in the proper use and care of the equipment and/or supplies described.

  • I have had my financial responsibilities explained.
  • I also acknowledge and agree to this entire agreement.

I, ______have read and acknowledged the above information Date:______

(Patient Signature)

Qualified Fitter: ______Date:______