You may be eligible for shoes – at no cost to you! Enter your information in the form below to find out if you qualify for shoe coverage. Medicare or your insurance provider may cover the cost of one pair of shoes and three pairs of custom or heat molded insoles per calendar year. Find out if you qualify now!

Besides Medicare, here is a list of private insurance providers: AARP United Health Care, Aetna, Anthem BCBS,ChampVA, Coventry, Empire BCBS, Humana, Blue Cross Blue Shield, Care Improvement, Pyramid, Secure Horizons, United Health Care, Tricare,Wellcare. Any many more.

Personal Information










Medicare And Insurance Information

Is Medicare Your Primary Insurance?

Medicare:



Supplementary / Secondary Insurance Information



Primary Physician Information (M.D Or D.O Only No Podiatrist Please)







Medicare Covered Products (Check Next To Each Product You Want To Receive)

 Tens Unit Ankle Brace Seat Lift Knee Brace Back Brace Wrist Brace



Confirm & Submit Application

Additional Comments



By submitting this information, I authorize NoCostShoes.com/Quantum Medical Supply Inc., its affiliates, subsidiaries, or parent company to contact me by phone or email. Please be assured that we value and protect your privacy. Remember, there is no purchase necessary to see if you qualify.