Get Medical Justification Form

MEDICAL EQUIPMENT REQUEST AND JUSTIFICATION www. manitoba.ca/fs/dhsu This request is in support of an individual enrolled in the following program s Employment and Income Assistance Children s disABILITY Services Community Living disABILITY Services Family Services is authorized to collect personal information and personal health information under section 36 1 b of The Freedom of Information and Protection of Privacy Act FIPPA and section 13 1 of The Personal Health Information Act PHIA respectively as the information is directly related to and necessary for the purposes of administering eligible supports provided by the programs identified at the top of this document and facilitating the procurement and delivery of medical supplies and equipment. Equipment requested Must demonstrate why the ACC is needed and how it will meet the child s needs. Identify the relationship between the client s medical needs and the Provide justification for components of equipment especially if they are considered to be up charges e.g. beyond basic and essential Is the ACC disability related and would not be required by a child of a similar age without a disability PLEASE FORWARD COMPLETED REQUEST ELECTRONICALLY E-MAIL FAX OR MAIL TO Disability and Health Supports Unit Provincial Services / 102 114 Garry Street Winnipeg MB R3C 1G1 TELEPHONE INQUIRIES PLEASE PHONE 204 945-2197 or toll free 1-877-587-6224 or FAX 204 945-1436 or E-MAIL disandhealthsupports gov.mb. If you have any questions about your information please contact the FIPPA Coordinator at 945-2013 at 500-326 Broadway Winnipeg MB R3C 0S5. o Section 1 to be completed on behalf of the applicant e.g. the client. Therapist. Justification letters for specialized equipment requests must be included in or attached to this request form. PROGRAM OBJECTIVE To provide basic cost effective medical equipment and devices to meet a medically essential need. SECTION 1 CLIENT INFORMATION CLIENT SURNAME GIVEN NAME MIDDLE INITIAL BIRTHDATE DD MM YY ADDRESS TOWN/CITY POSTAL CODE TELEPHONE/CONTACT NUMBER DELIVERY ADDRESS if different from above TOWN/CITY GENDER PHIN M F DATE OF REQUEST DD MM YY PARENT/GUARDIAN/AGENCY if applicable EIA CASE NUMBER if applicable HEIGHT ft/in and WEIGHT lbs ARE ANY OF THESE BENEFITS COVERED UNDER ANY OTHER PUBLIC OR PRIVATE HEALTH CARE PLAN e.g. RHA HEIGHT MPI BLUE CROSS WCB FNIHB or OTHER YES NO IF YES WHICH BENEFIT S DELIVERY INSTRUCTIONS if applicable SECTION 2 PRESCRIBER / REGULATED HEALTH PROFESSIONAL INFORMATION SURNAME FAX NUMBER E-MAIL ADDRESS IS THIS CLIENT PENDING HOSPITAL DISCHARGE SIGNATURE DISCHARGE DATE SECTION 3a STANDARD EQUIPMENT REQUEST Available in MDA Catalogue DIAGNOSIS DESCRIBE THE IMPACT OF THE CLIENTS MEDICAL CONDITION ON DAILY FUNCTIONING ORGANIZATION CATALOGUE PRODUCTS See the MDA Medical Products Catalogue if Applicable additional items can be attached on a separate sheet SAP QUANTITY PRODUCT DESCRIPTION SECTION 3b SPECIALIZED EQUIPMENT REQUEST Please include justification letter/report to support the request as instructed below EXAMPLES OF RELEVANT INFORMATION TO JUSTIFY SPECIALIZED EQUIPMENT REQUESTS i.e. lift systems tracking ramps etc. ASSESSMENT FINDINGS FUNCTIONAL/ ENVIRONMENT SUMMARY What precipitated the request If required has a home assessment been completed What are the outcomes/goals for use of requested equipment/device Functional status e.g. mobility transfers ADL skills Health information Physical skills or limitations as it relates to the equipment requested - Relevant medical interventions include applicable medical reports Prognosis e.g. head control ROM vision balance etc. Cognitive skills as it relates to equipment requested e.g. visual spatial skills judgment etc. O Section 1 to be completed on behalf of the applicant e.g. the client. Therapist. Justification letters for specialized equipment requests must be included in or attached to this request form. PROGRAM OBJECTIVE To provide basic cost effective medical equipment and devices to meet a medically essential need. SECTION 1 CLIENT INFORMATION CLIENT SURNAME GIVEN NAME MIDDLE INITIAL BIRTHDATE DD MM YY ADDRESS TOWN/CITY POSTAL CODE TELEPHONE/CONTACT NUMBER DELIVERY ADDRESS if different from above TOWN/CITY GENDER PHIN M F DATE OF REQUEST DD MM YY PARENT/GUARDIAN/AGENCY if applicable EIA CASE NUMBER if applicable HEIGHT ft/in and WEIGHT lbs ARE ANY OF THESE BENEFITS COVERED UNDER ANY OTHER PUBLIC OR PRIVATE HEALTH CARE PLAN e.g. RHA HEIGHT MPI BLUE CROSS WCB FNIHB or OTHER YES NO IF YES WHICH BENEFIT S DELIVERY INSTRUCTIONS if applicable SECTION 2 PRESCRIBER / REGULATED HEALTH PROFESSIONAL INFORMATION SURNAME FAX NUMBER E-MAIL ADDRESS IS THIS CLIENT PENDING HOSPITAL DISCHARGE SIGNATURE DISCHARGE DATE SECTION 3a STANDARD EQUIPMENT REQUEST Available in MDA Catalogue DIAGNOSIS DESCRIBE THE IMPACT OF THE CLIENTS MEDICAL CONDITION ON DAILY FUNCTIONING ORGANIZATION CATALOGUE PRODUCTS See the MDA Medical Products Catalogue if Applicable additional items can be attached on a separate sheet SAP QUANTITY PRODUCT DESCRIPTION SECTION 3b SPECIALIZED EQUIPMENT REQUEST Please include justification letter/report to support the request as instructed below EXAMPLES OF RELEVANT INFORMATION TO JUSTIFY SPECIALIZED EQUIPMENT REQUESTS i.e. lift systems tracking ramps etc. ASSESSMENT FINDINGS FUNCTIONAL/ ENVIRONMENT SUMMARY What precipitated the request If required has a home assessment been completed What are the outcomes/goals for use of requested equipment/device Functional status e.g. mobility transfers ADL skills Health information Physical skills or limitations as it relates to the equipment requested - Relevant medical interventions include applicable medical reports Prognosis e.g. head control ROM vision balance etc. Cognitive skills as it relates to equipment requested e.g. visual spatial skills judgment etc. ENVIRONMENT AND OTHER SUPPORTS PRODUCT PARAMETERS Indicate the type and status of present equipment and why it no longer Identify possible equipment solutions more than one possible solution. meets the needs of the client. Specify product parameters and provide medical justification for each.