"Enteral Feeding Application" - New Brunswick, Canada

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SOCIAL DEVELOPMENT
Health Services
HEALTH SERVICES
P.O. Box 5500, Fredericton, N.B., E3B 5G4
Toll Free: 1 (844) 551-3015
Clear form
Fax: (506) 453-3960
ENTERAL FEEDING APPLICATION
D
The purpose of this form is for Social Development - Health Services to obtain enough medical information to determine
eligibility for the Enteral Feeding benefit.
The Application Process: 1) Authorized prescriber completes application 2) Application submitted to pharmacy/supplier
3) Pharmacy/supplier sends application and cost estimate to Health Services for a decision
1. Prescriber
2. Pharmacy/
3. Health Services
Supplier
Application
Cost Est.
CLIENT INFORMATION
LAST NAME:
FIRST NAME:
DATE OF BIRTH:
S.D. HEALTH CARD #:
NB MEDICARE #:
SECTIONS 1 & 2 ARE FOR AUTHORIZED PRESCRIBERS ONLY: PHYSICIAN, NURSE PRACTITIONER, AND REGISTERED DIETICIAN
SECTIONS 1 & 2 MUST BE COMPLETED. INCOMPLETE FORMS WILL DELAY PROCESSING.
1)
ENTERAL FEEDING BENEFIT
MANDATORY
Please provide DIAGNOSIS and EXPLANATION why the patient requires enteral feeding:
2)
RECOMMENDED PRODUCT: Any changes in product or quantity must be forwarded to pharmacy/supplier and
approved by Health Services
Product
Quantity
Duration of Need
3)
AUTHORIZED PRESCRIBER INFORMATION – ALL FIELDS ARE MANDATORY
PRESCRIBER’S STAMP (NAME and DESIGNATION)
PRESCRIBER’S INFORMATION
PRESCRIBER’S
SIGNATURE:
TELEPHONE #:
FAX #:
DATE:
AUTHORIZED PRESCRIBER: FORWARD COMPLETED APPLICATION TO PHARMACY/SUPPLIER
PHARMACY/SUPPLIER: SUBMIT APPLICATION AND COST ESTIMATE TO HEALTH SERVICES
November 2019
SOCIAL DEVELOPMENT
Health Services
HEALTH SERVICES
P.O. Box 5500, Fredericton, N.B., E3B 5G4
Toll Free: 1 (844) 551-3015
Clear form
Fax: (506) 453-3960
ENTERAL FEEDING APPLICATION
D
The purpose of this form is for Social Development - Health Services to obtain enough medical information to determine
eligibility for the Enteral Feeding benefit.
The Application Process: 1) Authorized prescriber completes application 2) Application submitted to pharmacy/supplier
3) Pharmacy/supplier sends application and cost estimate to Health Services for a decision
1. Prescriber
2. Pharmacy/
3. Health Services
Supplier
Application
Cost Est.
CLIENT INFORMATION
LAST NAME:
FIRST NAME:
DATE OF BIRTH:
S.D. HEALTH CARD #:
NB MEDICARE #:
SECTIONS 1 & 2 ARE FOR AUTHORIZED PRESCRIBERS ONLY: PHYSICIAN, NURSE PRACTITIONER, AND REGISTERED DIETICIAN
SECTIONS 1 & 2 MUST BE COMPLETED. INCOMPLETE FORMS WILL DELAY PROCESSING.
1)
ENTERAL FEEDING BENEFIT
MANDATORY
Please provide DIAGNOSIS and EXPLANATION why the patient requires enteral feeding:
2)
RECOMMENDED PRODUCT: Any changes in product or quantity must be forwarded to pharmacy/supplier and
approved by Health Services
Product
Quantity
Duration of Need
3)
AUTHORIZED PRESCRIBER INFORMATION – ALL FIELDS ARE MANDATORY
PRESCRIBER’S STAMP (NAME and DESIGNATION)
PRESCRIBER’S INFORMATION
PRESCRIBER’S
SIGNATURE:
TELEPHONE #:
FAX #:
DATE:
AUTHORIZED PRESCRIBER: FORWARD COMPLETED APPLICATION TO PHARMACY/SUPPLIER
PHARMACY/SUPPLIER: SUBMIT APPLICATION AND COST ESTIMATE TO HEALTH SERVICES
November 2019