Form HR2138 "Medical Equipment Request and Justification" - British Columbia, Canada

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Medical Equipment
Request and Justification
The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Employment and Assistance for Persons With Disabilities Act. The
collection, use and disclosure of personal information is subject to the provisions of the Freedom of Information and Protection of Privacy Act. If you have any questions about the collection, use or disclosure
of this information, please contact your local Employment and Assistance Office.
Program Objective: To provide the most basic, least costly medical equipment and devices to meet a medically essential need. Full details
on eligibility criteria can be found on the ministry's Policy & Procedure Manual at:
www2.gov.bc.ca/gov/content/governments/policies-for-
government/bcea-policy-and-procedure-manual/health-supplements-and-programs/medical-equipment-and-devices
Section 1 – Client Information
(to be completed by worker)
Client Last Name
Client First Name
Telephone or Message
Birth Date (YYYY MMM DD)
Personal Health Number (PID)
[care card #]
Client Street Address (if Residential Care Facility, Name of Facility)
City/Town
Postal Code
1.
Is client eligible to access medical equipment under the employment and assistance or employment and assistance for
Yes
No
persons with disabilities regulations?
2.
Are there other resources available to provide the requested medical equipment? (for example, ICBC, WorkSafeBC,
Yes
No
Department of Veteran Affairs, private insurance)
Please explain
Signature of Worker
Office Code
Date Signed (YYYY MMM DD)
Worker Number
I hereby give my permission for any medical practitioner or nurse practitioner, hospital or agency to give any medical information relevant to this application
to the Ministry of Social Development and Poverty Reduction and my permission for the Ministry of Social Development and Poverty Reduction to discuss
this request with the evaluating professionals. The medical equipment recommended has been described to me and I agree with the recommendations.
Signature of Client
Date Signed (YYYY MMM DD)
Note: an occupational, physical or respiratory therapist will provide the detailed
Section 2 – Medical or Nurse Practitioner Recommendation
specifications and functional assessment concerning the medical equipment requested.
Describe the medical condition of your patient
What type of medical equipment is recommended?
Signature of Medical Practitioner/Nurse Practitioner
Telephone
Date Signed (YYYY MMM DD)
Section 3 - Assessment (to be completed by Occupational, Physical or Respiratory Therapist)


An assessment should contain the following information:
Functional/environmental summary

Occupational or Physical Therapist Assessment
Functional status (i.e. mobility, transfers, ADL skills)


What has precipitated the request?

Physical skills or limitations as it relates to the equipment

What are the outcomes/goals for use of requested equipment/device?
requested (i.e. head control, ROM, vision, balance, etc.)

Health information

Cognitive skills as it relates to equipment request (i.e. visual spatial
Relevent medical interventions (include medical reports

skills, judgment, etc.)
if applicable)
Diagnosis/prognosis

Height and weight

Page of
HR2138 (18/07/15)
Security Classification: MEDIUM SENSITIVITY
Medical Equipment
Request and Justification
The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Employment and Assistance for Persons With Disabilities Act. The
collection, use and disclosure of personal information is subject to the provisions of the Freedom of Information and Protection of Privacy Act. If you have any questions about the collection, use or disclosure
of this information, please contact your local Employment and Assistance Office.
Program Objective: To provide the most basic, least costly medical equipment and devices to meet a medically essential need. Full details
on eligibility criteria can be found on the ministry's Policy & Procedure Manual at:
www2.gov.bc.ca/gov/content/governments/policies-for-
government/bcea-policy-and-procedure-manual/health-supplements-and-programs/medical-equipment-and-devices
Section 1 – Client Information
(to be completed by worker)
Client Last Name
Client First Name
Telephone or Message
Birth Date (YYYY MMM DD)
Personal Health Number (PID)
[care card #]
Client Street Address (if Residential Care Facility, Name of Facility)
City/Town
Postal Code
1.
Is client eligible to access medical equipment under the employment and assistance or employment and assistance for
Yes
No
persons with disabilities regulations?
2.
Are there other resources available to provide the requested medical equipment? (for example, ICBC, WorkSafeBC,
Yes
No
Department of Veteran Affairs, private insurance)
Please explain
Signature of Worker
Office Code
Date Signed (YYYY MMM DD)
Worker Number
I hereby give my permission for any medical practitioner or nurse practitioner, hospital or agency to give any medical information relevant to this application
to the Ministry of Social Development and Poverty Reduction and my permission for the Ministry of Social Development and Poverty Reduction to discuss
this request with the evaluating professionals. The medical equipment recommended has been described to me and I agree with the recommendations.
Signature of Client
Date Signed (YYYY MMM DD)
Note: an occupational, physical or respiratory therapist will provide the detailed
Section 2 – Medical or Nurse Practitioner Recommendation
specifications and functional assessment concerning the medical equipment requested.
Describe the medical condition of your patient
What type of medical equipment is recommended?
Signature of Medical Practitioner/Nurse Practitioner
Telephone
Date Signed (YYYY MMM DD)
Section 3 - Assessment (to be completed by Occupational, Physical or Respiratory Therapist)


An assessment should contain the following information:
Functional/environmental summary

Occupational or Physical Therapist Assessment
Functional status (i.e. mobility, transfers, ADL skills)


What has precipitated the request?

Physical skills or limitations as it relates to the equipment

What are the outcomes/goals for use of requested equipment/device?
requested (i.e. head control, ROM, vision, balance, etc.)

Health information

Cognitive skills as it relates to equipment request (i.e. visual spatial
Relevent medical interventions (include medical reports

skills, judgment, etc.)
if applicable)
Diagnosis/prognosis

Height and weight

Page of
HR2138 (18/07/15)
Security Classification: MEDIUM SENSITIVITY
Medical Equipment
Request and Justification

Environment and other supports

Equipment trialed

Current equipment (related to requested equipment)

Indicate each piece of equipment/device trialed and outcome of
Indicate the type and status of present equipment and

trial
why it is no longer meeting the needs of the client?

Document reason for elimination of some options

What repairs or modifications have been done to

Justification
current equipment?

Identify the relationship between the client's medical needs and
What is the cost of repairing present equipment?
the equipment requested

What was the funding source of the current equipment?
Provide justification for components of equipment especially if

they are considered to be “Up Charges”
Product parameters

Indicate the expected targeted outcomes for the equipment
Identify possible equipment solutions (Is there more than

requested
one possible solution?)

Specify product parameters, and provide medical
justification for each
Respiratory Therapist Assessment
Buyout

Trial
Therapeutic sleep test (e.g. overnight oximetry on CPAP or



Diagnostic sleep tests (e.g. overnight oximetry on
therapeutic polysomnogram)
room air, diagnostic polysomnogram)

Compliance report

Quote from supplier for trial/rental of CPAP/BIPAP

Quote for buyout of CPAP/BIPAP
Specifications of medical equipment required to meet the applicant's need
Therapist Name
Address
Telephone
Signature of Therapist
Date Signed (YYYY MMM DD)
I certify I have assessed the medical needs of the applicant in
section 1 and the recommended medical equipment will satisfy
his/her medical needs.
NOTE – Forward completed form to:
Ministry of Social Development and Poverty Reduction, Health Assistance
P.O. Box 9971 Stn Prov Govt
Victoria, BC V8W 9R5
Page of
HR2138 (18/07/15)
Security Classification: MEDIUM SENSITIVITY
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