Orthoses Request And Justification
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1
2ORTHOSES
REQUEST AND JUSTIFICATION
The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Employment and Assistance Act
and the Employment and Assistance for Persons with Disabilities Act. The collection, use and disclosure of personal information is subject to the provisions of the Freedom
of Information and Protection of Privacy Act. Any questions about this information should be directed to your local Employment and Assistance Office.
PROGRAM OBJECTIVE: To provide the most basic, least costly orthoses to meet a medically essential need. Full details on eligibility
criteria can be found on the ministry’s Online Resource Policy Manual at:
SECTION 1 – CLIENT INFORMATION (to be completed by worker)
CLIENT SURNAME
CLIENT GIVEN NAME
PHONE NUMBER
BIRTH DATE
PERSONAL HEALTH NUMBER
[Care Card]
CLIENT STREET ADDRESS (IF RESIDENTIAL CARE FACILITY, NAME OF FACILITY)
CITY / TOWN
POSTAL CODE
1.
IS CLIENT ELIGIBLE TO ACCESS MEDICAL EQUIPMENT UNDER THE
YES
NO
EMPLOYMENT AND ASSISTANCE OR EMPLOYMENT AND ASSISTANCE FOR
PERSONS WITH DISABILITIES REGULATIONS?
2.
ARE THERE OTHER RESOURCES AVAILABLE TO PROVIDE THE REQUESTED
YES
NO
ORTHOSIS? (for example, ICBC, WorkSafeBC, Veterans Affairs, private insurance)
PLEASE EXPLAIN:
SIGNATURE OF WORKER
OFFICE CODE/BRANCH
WORKER NUMBER
DATE SIGNED (YYYY MMM DD)
I HEREBY GIVE MY PERMISSION FOR ANY MEDICAL PRACTITIONER OR NURSE PRACTITIONER, HOSPITAL OR AGENCY TO GIVE ANY
MEDICAL INFORMATION RELEVANT TO THIS APPLICATION TO THE MINISTRY OF SOCIAL DEVELOPMENT AND MY PERMISSION FOR THE
MINISTRY OF SOCIAL DEVELOPMENT TO DISCUSS THIS REQUEST WITH THE EVALUATING PROFESSIONALS. THE ORTHOSIS
RECOMMENDED HAS BEEN DESCRIBED TO ME AND I AGREE WITH THE RECOMMENDATIONS.
DATE SIGNED (YYYY MMM DD)
CLIENT SIGNATURE
SECTION 2 – MEDICAL OR NURSE PRACTITIONER RECOMMENDATION
DESCRIBE THE MEDICAL CONDITION OF YOUR PATIENT
WHAT TYPE OF ORTHOSIS IS RECOMMENDED?
IS A CUSTOM-MADE ORTHOSIS REQUIRED?
YES
NO
IF THE ORTHOSIS IS A KNEE BRACE, WILL IT BE REQUIRED AT LEAST 6 HOURS PER DAY?
YES
NO
SIGNATURE OF MEDICAL PRACTITIONER/NURSE PRACTITIONER
PHONE NUMBER
DATE SIGNED (YYYY MMM DD)
NOTE: IF CUSTOM ORTHOSIS REQUIRED, PLEASE REFER PATIENT TO AN ORTHOTIST, PEDORTHIST,
PODIATRIST, OCCUPATIONAL THERAPIST OR PHYSICAL THERAPIST
Page 1 of 2
HR2894(14/04/17)
Security Classification: MEDIUM SENSITIVITY
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