"Request for Blood Glucose Test Supplies" - New Brunswick, Canada

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Social Development
Développement social
Self-reliance, an improved quality of life,
L’autonomie, une meilleure qualité de vie
and protection for those who need it.
et une protection pour ceux qui en ont besoin.
Request for Blood Glucose Test Supplies
This form must be completed by a Physician, Nurse Practitioner or a Certified Diabetes Educator (CDE)
PATIENT INFORMATION
Patient’s Last Name:
First Name:
Middle Name:
Health Card ID:
Date of Birth (YYYY/MM/DD):
Mailing Address:
Today’s Date (YYYY/MM/DD):
Note: This request is valid for 1 year only, starting with the date above. Social Development
will monitor and evaluate the information provided. The quantities of strips noted below
,
indicate the annual maximums for reimbursement.
NUMBER OF TEST STRIPS PERMITTED FOR SELF-MONITORING OF BLOOD GLUCOSE (SMBG)
(CHECK ONLY ONE BOX)
Annual
Exceptional Circumstances
Patient Category
Allowance
(two additional requests permitted annually)
Newly diagnosed type 2 diabetes
 50 strips and
Additional 50 strips and associated testing supplies
receiving no antidiabetes drugs
associated
because this patient has:
* For most adults with type 2 diabetes who control their
 Acute illness, significant change in routine, or
testing supplies
diabetes through diet alone, routine SMBG is not
changes in drug dose or regimen
required.
 Poorly controlled or unstable blood glucose levels
Type 2 diabetes receiving oral drugs
 100 strips
 History of, or increased risk of, hypoglycemia
(e.g., metformin, secretagogue, DPP-4
(dispensed in
 Occupation in which hypoglycemia poses a safety
quantities of up to
inhibitor, etc.)
hazard
50 strips every six
* For most adults with type 2 diabetes who are taking oral
antidiabetes drugs, routine SMBG is not required. Testing
 Trying to become pregnant
months) and
may be required in some situations, but only if it helps to
associated testing
Note: In extenuating circumstances a special request for additional
determine a specific course of action.
supplies
strips may be made in the form of a letter by a physician or nurse
practitioner if there is a specific identified medical need.
 Individualize to achieve optimal glucose control.
Gestational diabetes, or type 2 diabetes
and pregnant but not receiving insulin
_____ strips and associated testing supplies every month x _____ month(s)
* The optimal daily frequency of SMBG should be
individualized for most women with gestational diabetes
EDC: __________________________
not using diabetes pharmacotherapy.
Type 1 or type 2 diabetes receiving
 Individualize to guide adjustments in insulin therapy to achieve optimal
insulin
glucose control.
* Most adults with type 2 diabetes receiving basal insulin
_____ strips and associated testing supplies every month x _____ month(s)
require no more than 14 tests each week on average.
Supplies are required to administer insulin _________ x per day
* Optimal Therapy Recommendations for the Prescribing and Use of Blood Glucose Test Strips. Ottawa: CADTH; 2009 Jul. Available from:
www.cadth.ca/media/pdf/compus_BGTS_OT_Rec_e.pdf, and Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using
insulin. Cochrane Database of Systematic Reviews 2012, Issue 1. Art. No.: CD005060. DOI: 10.1002/14651858.CD005060.pub3.
REQUESTOR INFORMATION
Requestor Address:
Name:
Physician license or Nurse Practitioner Prescriber number:
or
CDE certification number:
Telephone and Fax Numbers:
Requestor signature:
Please return the completed form and a Pharmacy estimate to your local Social Development office
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Reset
Social Development
Développement social
Self-reliance, an improved quality of life,
L’autonomie, une meilleure qualité de vie
and protection for those who need it.
et une protection pour ceux qui en ont besoin.
Request for Blood Glucose Test Supplies
This form must be completed by a Physician, Nurse Practitioner or a Certified Diabetes Educator (CDE)
PATIENT INFORMATION
Patient’s Last Name:
First Name:
Middle Name:
Health Card ID:
Date of Birth (YYYY/MM/DD):
Mailing Address:
Today’s Date (YYYY/MM/DD):
Note: This request is valid for 1 year only, starting with the date above. Social Development
will monitor and evaluate the information provided. The quantities of strips noted below
,
indicate the annual maximums for reimbursement.
NUMBER OF TEST STRIPS PERMITTED FOR SELF-MONITORING OF BLOOD GLUCOSE (SMBG)
(CHECK ONLY ONE BOX)
Annual
Exceptional Circumstances
Patient Category
Allowance
(two additional requests permitted annually)
Newly diagnosed type 2 diabetes
 50 strips and
Additional 50 strips and associated testing supplies
receiving no antidiabetes drugs
associated
because this patient has:
* For most adults with type 2 diabetes who control their
 Acute illness, significant change in routine, or
testing supplies
diabetes through diet alone, routine SMBG is not
changes in drug dose or regimen
required.
 Poorly controlled or unstable blood glucose levels
Type 2 diabetes receiving oral drugs
 100 strips
 History of, or increased risk of, hypoglycemia
(e.g., metformin, secretagogue, DPP-4
(dispensed in
 Occupation in which hypoglycemia poses a safety
quantities of up to
inhibitor, etc.)
hazard
50 strips every six
* For most adults with type 2 diabetes who are taking oral
antidiabetes drugs, routine SMBG is not required. Testing
 Trying to become pregnant
months) and
may be required in some situations, but only if it helps to
associated testing
Note: In extenuating circumstances a special request for additional
determine a specific course of action.
supplies
strips may be made in the form of a letter by a physician or nurse
practitioner if there is a specific identified medical need.
 Individualize to achieve optimal glucose control.
Gestational diabetes, or type 2 diabetes
and pregnant but not receiving insulin
_____ strips and associated testing supplies every month x _____ month(s)
* The optimal daily frequency of SMBG should be
individualized for most women with gestational diabetes
EDC: __________________________
not using diabetes pharmacotherapy.
Type 1 or type 2 diabetes receiving
 Individualize to guide adjustments in insulin therapy to achieve optimal
insulin
glucose control.
* Most adults with type 2 diabetes receiving basal insulin
_____ strips and associated testing supplies every month x _____ month(s)
require no more than 14 tests each week on average.
Supplies are required to administer insulin _________ x per day
* Optimal Therapy Recommendations for the Prescribing and Use of Blood Glucose Test Strips. Ottawa: CADTH; 2009 Jul. Available from:
www.cadth.ca/media/pdf/compus_BGTS_OT_Rec_e.pdf, and Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using
insulin. Cochrane Database of Systematic Reviews 2012, Issue 1. Art. No.: CD005060. DOI: 10.1002/14651858.CD005060.pub3.
REQUESTOR INFORMATION
Requestor Address:
Name:
Physician license or Nurse Practitioner Prescriber number:
or
CDE certification number:
Telephone and Fax Numbers:
Requestor signature:
Please return the completed form and a Pharmacy estimate to your local Social Development office
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