"Health Services Dietary Supplement Application" - New Brunswick, Canada

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Download "Health Services Dietary Supplement 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
DIETARY SUPPLEMENT APPLICATION
D
The purpose of this form is for Social Development - Health Services to obtain enough medical information to determine
eligibility for the Dietary Supplement Program.
The Application Process: 1) Client presents application 2) Authorized prescriber completes application 3) Application submitted to
pharmacy 4) Pharmacy sends application and cost estimate to Health Services for a decision
1. Client
2. Prescriber
3. Pharmacy
4. Health Services
Application
Application
Cost Est.
CLIENT INFORMATION
LAST NAME:
FIRST NAME:
DATE OF BIRTH:
S.D. HEALTH CARD #:
NB MEDICARE #:
SECTIONS 1, 2 & 3 ARE FOR AUTHORIZED PRESCRIBERS ONLY: PHYSICIAN, NURSE PRACTITIONER, REGISTERED
DIETICIAN, SPEECH THERAPIST
SECTIONS 1, 2 & 3 MUST BE COMPLETED. INCOMPLETE FORMS WILL DELAY PROCESSING.
1) DIETARY SUPPLEMENT BENEFIT: Check applicable conditions and provide diagnosis and explanation.
MANDATORY (Indicate at least one)
MANDATORY
DIAGNOSIS and EXPLANATION why patient
Date of trauma:
 Major physical trauma
cannot eat real food (including pureed):
Date of surgery:
 Preoperative period
 Postoperative period
Current BMI or other measure:
 Significant weight loss only
 Moderate to severe immune suppression
(Complete diagnosis / explanation)
Year of treatment:
 Receiving chemotherapy, radiation
or interferon treatment
 GI malabsorption syndrome
(Complete diagnosis / explanation)
 Neurological degeneration
(Complete diagnosis / explanation)
 No medical justification for this benefit
(Complete diagnosis / explanation)
2) RECOMMENDED TREATMENT
PRODUCT
QUANTITY
DURATION OF NEED
Generic given unless medical justification
Number of cans
Request for 6+ months requires a letter of explanation
for brand name is provided
(max 4/day)
 3 months
 12 months (+ letter)
 6 months
 Long term (+ letter)
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 BY CLIENT OR FAX
PHARMACY: 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
DIETARY SUPPLEMENT APPLICATION
D
The purpose of this form is for Social Development - Health Services to obtain enough medical information to determine
eligibility for the Dietary Supplement Program.
The Application Process: 1) Client presents application 2) Authorized prescriber completes application 3) Application submitted to
pharmacy 4) Pharmacy sends application and cost estimate to Health Services for a decision
1. Client
2. Prescriber
3. Pharmacy
4. Health Services
Application
Application
Cost Est.
CLIENT INFORMATION
LAST NAME:
FIRST NAME:
DATE OF BIRTH:
S.D. HEALTH CARD #:
NB MEDICARE #:
SECTIONS 1, 2 & 3 ARE FOR AUTHORIZED PRESCRIBERS ONLY: PHYSICIAN, NURSE PRACTITIONER, REGISTERED
DIETICIAN, SPEECH THERAPIST
SECTIONS 1, 2 & 3 MUST BE COMPLETED. INCOMPLETE FORMS WILL DELAY PROCESSING.
1) DIETARY SUPPLEMENT BENEFIT: Check applicable conditions and provide diagnosis and explanation.
MANDATORY (Indicate at least one)
MANDATORY
DIAGNOSIS and EXPLANATION why patient
Date of trauma:
 Major physical trauma
cannot eat real food (including pureed):
Date of surgery:
 Preoperative period
 Postoperative period
Current BMI or other measure:
 Significant weight loss only
 Moderate to severe immune suppression
(Complete diagnosis / explanation)
Year of treatment:
 Receiving chemotherapy, radiation
or interferon treatment
 GI malabsorption syndrome
(Complete diagnosis / explanation)
 Neurological degeneration
(Complete diagnosis / explanation)
 No medical justification for this benefit
(Complete diagnosis / explanation)
2) RECOMMENDED TREATMENT
PRODUCT
QUANTITY
DURATION OF NEED
Generic given unless medical justification
Number of cans
Request for 6+ months requires a letter of explanation
for brand name is provided
(max 4/day)
 3 months
 12 months (+ letter)
 6 months
 Long term (+ letter)
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 BY CLIENT OR FAX
PHARMACY: SUBMIT APPLICATION AND COST ESTIMATE TO HEALTH SERVICES
November 2019