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Health.qld.gov.au/mass MASS60 v .0 - 0 /2014 Page 2 of 2 The State of Queensland (Queensland Health) 2012 Contact CIM health.qld.gov.au (Affix identification label here if available) Medical Aids Subsidy Scheme (MASS) Queensland Health Family name: MASS 60 Medical Grade Footwear Application Form Given name(s): This form is used for medical grade footwear applications Date of birth: Sex: M F PART A To be completed by the applicant / carer Applicant s Personal Details 9 Does.

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