"Application for Ventilation Equipment" - New Brunswick, Canada

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S
D
OCIAL
EVELOPMENT
DÉVELOPPEMENT SOCIAL
Health Services Program
Programme des services de santé
P.O. Box 5500, Frederiction, N.B., E3B 5G4
C.P. 5500, Fredericton N.-B., E3B 5G4
Toll Free: 1-844-551-3015
Sans Frais: 1-844-551-3015
Fax: (506) 453-3960
Télécopieur: (506) 453-3960
A
V
E
Clear / Effacer
P P L I C A T I O N F O R
E N T I L A T I O N
Q U I P M E N T
P
A : C
I
A R T
L I E N T
N F O R M A T I O N
LAST NAME
FIRST NAME
DATE OF BIRTH
ADDRESS /
CITY, TOWN, VILLAGE
POSTAL CODE
TELEPHONE
HEALTH CARD NUMBER
PRIVATE INSURANCE
Yes / Oui
No / Non
P
B : P
& R
T
A R T
R E S C R I B E R
E S P I R A T O R Y
H E R A P I S T I N F O R M A T I O N
RESPIROLOGIST
INTENSIVIST
PHYSIATRIST
P R E S C R I B I N G P H Y S I C I A N C O N T A C T I N F O R M A T I O N
NAME :
SIGNATURE :
TELEPHONE :
DATE :
R E S P I R A T O R Y T H E R A P I S T C O N T A C T I N F O R M A T I O N
NAME / NOM :
TELEPHONE
P
C : D
A R T
I A G N O S I S
ALS / Motor Neuron Disease
Duchenes Muscular Dystrophy
Spinal Cord Injury / Tetraplegia
Central Hypoventilation
Kyphoscoliosis
Other Neuromuscular Degenerative Disease evolving to
Polio / Post Polio
ventilation support because of clinical presentation:
Spinal Muscular Atrophy
P
D : C
D
A R T
L I N I C A L
A T A
* M a n d a t o r y f o r c o u g h a s s i s t < 2 0 0 l / m i n
Notes:
IPAP:
FVC
*Peak Cough Flow
EPAP:
SNIP
MIP / MEP
Respiratory Rate:
Blood Gas
Oximetry
P
E : P
P
A R T
R E S C R I P T I O N
H A S E
Early intervention: patient requires nocturnal BPAP with AVAPS. Lung Recruitment Volume exercises taught. No significant
Phase I
bulbar involvement
BPAP with AVAPS nocturnal and daytime PRN use. Swallow/ cough impairment. Oral aspirator, mechanical in/ ex sufflator
Phase II
for airway clearance
Phase III
BPAP with AVAPS required 18-22 hours daily; options for palliation or extended life discussed and chosen by patient.
Phase IV a
Palliation; patient choose not to be intubated; BPAP with AVAPS continuous, in/ex sufflation as per patient choice.
Phase IV b
Elective intubation/ tracheotomy, with planned volume or pressure controlled ventilation
Emergency intubation; patient chooses intubation as last resort; volume or pressure controlled ventilator with initial non-
Phase IV c
invasive interface; plan for future elective or emergency intubation.
PLEASE ADVISE HEALTH SERVICES OF ANY CHANGES / SVP AVISER LES SERVICES DE SANTÉ DE TOUT CHANGEMENTS
…/2
S
D
OCIAL
EVELOPMENT
DÉVELOPPEMENT SOCIAL
Health Services Program
Programme des services de santé
P.O. Box 5500, Frederiction, N.B., E3B 5G4
C.P. 5500, Fredericton N.-B., E3B 5G4
Toll Free: 1-844-551-3015
Sans Frais: 1-844-551-3015
Fax: (506) 453-3960
Télécopieur: (506) 453-3960
A
V
E
Clear / Effacer
P P L I C A T I O N F O R
E N T I L A T I O N
Q U I P M E N T
P
A : C
I
A R T
L I E N T
N F O R M A T I O N
LAST NAME
FIRST NAME
DATE OF BIRTH
ADDRESS /
CITY, TOWN, VILLAGE
POSTAL CODE
TELEPHONE
HEALTH CARD NUMBER
PRIVATE INSURANCE
Yes / Oui
No / Non
P
B : P
& R
T
A R T
R E S C R I B E R
E S P I R A T O R Y
H E R A P I S T I N F O R M A T I O N
RESPIROLOGIST
INTENSIVIST
PHYSIATRIST
P R E S C R I B I N G P H Y S I C I A N C O N T A C T I N F O R M A T I O N
NAME :
SIGNATURE :
TELEPHONE :
DATE :
R E S P I R A T O R Y T H E R A P I S T C O N T A C T I N F O R M A T I O N
NAME / NOM :
TELEPHONE
P
C : D
A R T
I A G N O S I S
ALS / Motor Neuron Disease
Duchenes Muscular Dystrophy
Spinal Cord Injury / Tetraplegia
Central Hypoventilation
Kyphoscoliosis
Other Neuromuscular Degenerative Disease evolving to
Polio / Post Polio
ventilation support because of clinical presentation:
Spinal Muscular Atrophy
P
D : C
D
A R T
L I N I C A L
A T A
* M a n d a t o r y f o r c o u g h a s s i s t < 2 0 0 l / m i n
Notes:
IPAP:
FVC
*Peak Cough Flow
EPAP:
SNIP
MIP / MEP
Respiratory Rate:
Blood Gas
Oximetry
P
E : P
P
A R T
R E S C R I P T I O N
H A S E
Early intervention: patient requires nocturnal BPAP with AVAPS. Lung Recruitment Volume exercises taught. No significant
Phase I
bulbar involvement
BPAP with AVAPS nocturnal and daytime PRN use. Swallow/ cough impairment. Oral aspirator, mechanical in/ ex sufflator
Phase II
for airway clearance
Phase III
BPAP with AVAPS required 18-22 hours daily; options for palliation or extended life discussed and chosen by patient.
Phase IV a
Palliation; patient choose not to be intubated; BPAP with AVAPS continuous, in/ex sufflation as per patient choice.
Phase IV b
Elective intubation/ tracheotomy, with planned volume or pressure controlled ventilation
Emergency intubation; patient chooses intubation as last resort; volume or pressure controlled ventilator with initial non-
Phase IV c
invasive interface; plan for future elective or emergency intubation.
PLEASE ADVISE HEALTH SERVICES OF ANY CHANGES / SVP AVISER LES SERVICES DE SANTÉ DE TOUT CHANGEMENTS
…/2
A
V
E
Client ID/No d’ID du client :
Page 2
PPLICATION FOR
ENTILATION
QUIPMENT
Client name / nom du client:
P
F : S
P
I
A R T
E R V I C E
R O V I D E R
N F O R M A T I O N
T O B E C O M P L E T E D B Y A N A U T H O R I S E D V E N D O R O N L Y
CONTACT NAME:
TELEPHONE :
FAX :
VENDOR :
VENDOR IDENTIFICATION NUMBER :
P
G : E
P
A R T
Q U I P M E N T
R E S C R I B E D
EQUIPMENT TO BE PURCHASED
EQUIPMENT TO BE RENTED
Cough Assist Machine (Mechanical Insuffulator-Exsufflator)
$
Bi-Level with VAPS
$
SPO
monitor
$
Ventilator-non invasive
$
2
Heated humidifier
$
Ventilator
$
O
saturation monitor
$
Table Top Sat Monitor
$
2
Oral/Endotracheal aspirator
$
$
Total
$
Total
$
0.00
0.00
SUPPLIES TO BE PROVIDED BY VENDOR ON A MONTHLY OR ANNUAL BASIS
Product Details (Brand name, type of item and serial number where applicable)
Cost (EA)
Quantity
Monthly
Annual
$
$
$
$
Total
0.00
$
Service Dates:
B E F O R E S U B M I T T I N G F O R Y O U R T R I A L O R P U R C H A S E , P L E A S E V E R I F Y T H E F O L L O W I N G
All necessary documentation specified in the Health Services Guidelines are included with this application.
Y / O
N / N
The client, and other household members, have received education relevant to the equipment provided and are willing to comply with the
treatment plan prescribed, including smoking cessation.
Y / O
N / N
Vendor Signature :
Signature du fournisseur :
Date :
Please include a copy of this document with your initial request for payment on the Health Services Claim Form. Thank you.
F O R O F F I C E U S E O N L Y
APPROVED
REFUSED
PENDING INFO
APPROVAL NUMBER
TRIAL 
PURCHASE 
Administrator
Administrateur
Date :
EXPIRES:
Comments
REGISTERED
DATE : __________________________
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