"Nutritional Products Program Application" - Saskatchewan, Canada

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RETURN BY MAIL TO:
MINISTRY OF HEALTH
Drug Plan & Extended Benefits Branch
3475 Albert Street
Regina, Saskatchewan
S4S 6X6
PHONE: 306-787-7121
Nutritional Products
FAX: 306-798-2022
Program Application
Type of Application:
Initial
Re-assessment
PATIENT IDENTIFICATION (to be completed by Dietitian)
Patient Surname
First Name
Date of Birth (Day/Month/Year)
Current Address
City/Town/Village
Postal Code
Health Services Number
Phone Number
(
)
If patient is under 18 years of age, name(s) of parent/guardian:
________________________________________________________
Is the patient/family currently receiving assistance with their nutritional product costs through another program such as social
assistance, palliative care, etc?
  No
  Yes
Specify:___________________________________________
CLINICAL INFORMATION (to be completed by Dietitian)
Description of medical condition indicating the need for nutritional product: (please indicate % of nutritional
requirements met through nutrition product)
Formula prescribed:
Anticipated volume per month:
Anticipated duration of therapy:
Estimated cost of formula per month:
Anticipated Product Vendor :
RETURN BY MAIL TO:
MINISTRY OF HEALTH
Drug Plan & Extended Benefits Branch
3475 Albert Street
Regina, Saskatchewan
S4S 6X6
PHONE: 306-787-7121
Nutritional Products
FAX: 306-798-2022
Program Application
Type of Application:
Initial
Re-assessment
PATIENT IDENTIFICATION (to be completed by Dietitian)
Patient Surname
First Name
Date of Birth (Day/Month/Year)
Current Address
City/Town/Village
Postal Code
Health Services Number
Phone Number
(
)
If patient is under 18 years of age, name(s) of parent/guardian:
________________________________________________________
Is the patient/family currently receiving assistance with their nutritional product costs through another program such as social
assistance, palliative care, etc?
  No
  Yes
Specify:___________________________________________
CLINICAL INFORMATION (to be completed by Dietitian)
Description of medical condition indicating the need for nutritional product: (please indicate % of nutritional
requirements met through nutrition product)
Formula prescribed:
Anticipated volume per month:
Anticipated duration of therapy:
Estimated cost of formula per month:
Anticipated Product Vendor :
2
REFERRAL INFORMATION (to be completed
by Dietitian)
Dietitian:
Telephone:
(
)
Signature:
Date:
Dietitian’s Address:
DECLARATION and CONSENT (to be completed by client/family)
I consent to allow Saskatchewan Health officials access to my and my dependent(s) prescription drug costs, obtained
through the Saskatchewan Health Drug Plan, for the purpose of calculating assistance with the cost of therapeutic nutrition
product(s) under consideration in this application.
“I declare that all the information I have provided in this application is complete and correct in all respects and fully discloses
my total income from all sources. It is a serious offense to make a false declaration. "I CONSENT TO, AND AUTHORIZE,
the release to Saskatchewan Health of any documentation whatsoever, held by any party, which may be required to verify
the information which I have provided on this application. I understand that such information includes, but is not limited to,
information regarding my income held by Canada Customs and Revenue Agency, my employer and other government
agencies. I further consent to the use of this information by Saskatchewan Health for the purposes of determining my
entitlement for other Health Care benefits or programs.”
_________________________________________________
______________________________________________________
Signature of Applicant or Parent/Guardian
Signature of Spouse
___________________________
_____________________________
Date
Date
_________________________________________________
______________________________________________________
Signature of Trustee/Guardian/Power of Attorney (if applicable)
Signature of Trustee/Guardian/Power of Attorney (if applicable)
___________________________
_____________________________
Date
Date
INCOME DECLARATION (to be completed by client/family)
Please attach the most recent Notice of Assessment form sent which clearly indicates your
qualifying family income (eg: client and spouse, both parents in the case of children)
Saskatchewan Health will treat all the information provided on this application confidentially.
ADDITIONAL INFORMATION
Include any written explanation or information that may help for the review of this request. For example, income
changes, new medications or nutritional products. (If providing additional information about capital gains,
please attach a copy of schedule 3). Ensure you include supporting documentation.
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