Form Hr2138 Draft - Medical Equipment Request And Justification Page 2

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MEDICAL EQUIPMENT
REQUEST AND JUSTIFICATION
ENVIRONMENT AND OTHER SUPPORTS
EQUIPMENT TRIALED
CURRENT EQUIPMENT (RELATED TO REQUESTED
INDICATE EACH PIECE OF EQUIPMENT/DEVICE TRIALED
EQUIPMENT)
AND OUTCOME OF TRIAL
INDICATE THE TYPE AND STATUS OF PRESENT
DOCUMENT REASON FOR ELIMINATION OF SOME
EQUIPMENT AND WHY IT IS NO LONGER MEETING
OPTIONS
THE NEEDS OF THE CLIENT
JUSTIFICATION
WHAT REPAIRS OR MODIFICATIONS HAVE BEEN
IDENTIFY THE RELATIONSHIP BETWEEN THE CLIENT'S
DONE TO CURRENT EQUIPMENT?
MEDICAL NEEDS AND THE EQUIPMENT REQUESTED
WHAT IS THE COST OF REPAIRING PRESENT
PROVIDE JUSTIFICATION FOR COMPONENTS OF
EQUIPMENT
EQUIPMENT ESPECIALLY IF THEY ARE CONSIDERED TO BE
WHAT WAS THE FUNDING SOURCE OF THE CURRENT
“UP CHARGES”
EQUIPMENT
INDICATE THE EXPECTED TARGETED OUTCOMES FOR THE
EQUIPMENT REQUESTED
PRODUCT PARAMETERS
IDENTIFY POSSIBLE EQUIPMENT SOLUTIONS (IS
THERE MORE THAN ONE POSSIBLE SOLUTION?)
SPECIFY PRODUCT PARAMETERS, AND PROVIDE
MEDICAL JUSTIFICATION FOR EACH
RESPIRATORY THERAPIST ASSESSMENT
BUYOUT
TRIAL
THERAPEUTIC SLEEP TEST (E.G. OVERNIGHT
DIAGNOSTIC SLEEP TESTS (E.G. OVERNIGHT
OXIMETRY ON CPAP OR THERAPEUTIC
OXIMETRY ON ROOM AIR, DIAGNOSTIC
POLYSOMNOGRAM)
POLYSOMNOGRAM)
COMPLIANCE REPORT
QUOTE FROM SUPPLIER FOR TRIAL/RENTAL OF
QUOTE FOR BUYOUT OF CPAP/BIPAP
CPAP/BIPAP
SPECIFICATIONS OF MEDICAL EQUIPMENT REQUIRED TO MEET THE APPLICANT'S NEED
THERAPIST NAME
ADDRESS
TELEPHONE
I CERTIFY I HAVE ASSESSED THE MEDICAL NEEDS OF
SIGNATURE OF THERAPIST
DATE SIGNED (YYYY MMM DD)
THE APPLICANT IN SECTION 1 AND THE RECOMMENDED
MEDICAL EQUIPMENT WILL SATISFY HIS/HER MEDICAL
NEEDS.
NOTE: Forward completed form to:
Ministry of Social Development and Social Innovation, Health Assistance Branch,
P.O. Box 9971 STN PROV GOVT
Victoria, BC V8W 9R5
Page of
HR2138(13/11/29)
Security Classification: MEDIUM

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