Form Hr2138 Draft - Medical Equipment Request And Justification printable pdf download

MEDICAL EQUIPMENT

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 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. If you have any questions about the collection, use or disclosure

of this information, please contact your local Employment and Assistance Office.

PROGRAM OBJECTIVE: To provide the most basic, least costly medical equipment and devices to meet a medically essential need. Full

details on eligibility criteria can be found on the ministry's Online Resource Policy Manual at:

https://gww.hsd.gov.bc.ca/intranet/meia/

online_resource

SECTION 1 - CLIENT INFORMATION (to be completed by worker)

CLIENT SURNAME

CLIENT GIVEN NAME

TELEPHONE OR MESSAGE

BIRTHDATE (YYYY MMM DD)

PERSONAL HEALTH NUMBER (PID)

[care card #]

CLIENT STREET ADDRESS (IF RESIDENTIAL CARE FACILITY, NAME OF FACILITY)

CITY/TOWN

POSTAL CODE

IS CLIENT ELIGIBLE TO ACCESS MEDICAL EQUIPMENT UNDER THE

EMPLOYMENT AND ASSISTANCE OR EMPLOYMENT AND ASSISTANCE

Yes

FOR PERSONS WITH DISABILITIES REGULATIONS?

ARE THERE OTHER RESOURCES AVAILABLE TO PROVIDE THE

Yes

REQUESTED MEDICAL EQUIPMENT? (for example, ICBC, WorkSafeBC,

Department of Veteran Affairs, private insurance)

PLEASE EXPLAIN

SIGNATURE OF WORKER

OFFICE CODE

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 SOCIAL INNOVATION AND

MY PERMISSION FOR THE MINISTRY OF HOUSING AND SOCIAL DEVELLOPMENT TO DISCUSS THIS REQUEST WITH THE EVALUATING

PROFESSIONALS. THE MEDICAL EQUIPMENT RECOMMENDED HAS BEEN DESCRIBED TO ME AND I AGREE WITH THE

RECOMMENDATIONS.

SIGNATURE OF CLIENT

DATE SIGNED (YYYY MMM DD)

NOTE: AN OCCUPATIONAL, PHYSICAL OR RESPIRATORY THERAPIST WILL PROVIDE

SECTION 2 - MEDICAL OR NURSE PRACTITIONER

THE DETAILED SPECIFICATIONS AND FUNCTIONAL ASSESSMENT CONCERNING THE

RECOMMENDATION

MEDICAL EQUIPMENT REQUESTED.

DESCRIBE THE MEDICAL CONDITION OF YOUR PATIENT

WHAT TYPE OF MEDICAL EQUIPMENT IS RECOMMENDED?

SIGNATURE OF MEDICAL PRACTITIONER/NURSE PRACTITIONER

TELEPHONE

DATE SIGNED (YYYY MMM DD)

SECTION 3 - ASSESSMENT (TO BE COMPLETED BY OCCUPATIONAL, PHYSICAL OR RESPIRITORY THERAPIST)

AN ASSESSMENT SHOULD CONTAIN THE FOLLOWING

INFORMATION:

FUNCTIONAL/ENVIRONMENTAL SUMMARY

OCCUPATIONAL OR PHYSICAL THERAPIST ASSESSMENT

FUNCTIONAL STATUS (I.E. MOBILITY, TRANSFERS, ADL

WHAT HAS PRECIPITATED THE REQUEST?

SKILLS)

WHAT ARE THE OUTCOMES/GOALS FOR USE OF REQUESTED

PHYSICAL SKILLS OR LIMITATIONS AS IT RELATES TO THE

EQUIPMENT/DEVICE?

EQUIPMENT REQUESTED (I.E. HEAD CONTROL, ROM,

HEALTH INFORMATION

VISION, BALANCE, ETC.

RELEVENT MEDICAL INTERVENTIONS (INCLUDE

COGNITIVE SKILLS AS IT RELATES TO EQUIPMENT REQUEST

MEDICAL REPORTS IF APPLICABLE)

(I.E. VISUAL SPATIAL SKILLS, JUDGMENT, ETC.

DIAGNOSIS/PROGNOSIS

HEIGHT AND WEIGHT

Page of

HR2138(13/11/29)

Security Classification: MEDIUM

Form Hr2138 Draft - Medical Equipment Request And Justification

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