"Diabetic Foot/Nail Care Application Form" - 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, Fredericton, NB E3B 5G4
C.P. 5500, Fredericton, NB E3B 5G4
Toll free number: 1-844-551-3015
Numéro sans frais: 1-844-551-3015
Télécopieur: (506) 453-3960
Fax: (506) 453-3960
Clear
Page 1 of 2
SOCIAL ASSISTANCE CLIENTS ONLY
DIABETIC FOOT/NAIL CARE APPLICATION FORM
THE FOLLOWING 5 STEPS MUST BE COMPLETED BEFORE THIS APPLICATION CAN BE PROCESSED:
1. Applicant must complete Client Information Section and provide form to their Physician, Nurse Practitioner or Certified
Diabetic Educator (CDE).
2. Physician, Nurse Practitioner or CDE must fill out Section 1 & Part A & B and return to client.
3. Client must choose Foot/Nail Service Provider and provide them the form.
4. Foot/Nail Care Service Provider must complete Section 2. (Note: Vendor number is required).
5. Completed form to be returned to:
Health Services Program
P.O. Box 5500, Fredericton, NB E3B 5G4
Fax: (506) 453-3960
TO BE COMPLETED BY THE APPLICANT
CLIENT INFORMATION SECTION
LAST NAME
FIRST NAME
DATE OF BIRTH
ADDRESS
CITY, TOWN
POSTAL CODE
S.D. HEALTH CARD #
TELEPHONE
TO BE COMPLETED BY A PHYSICIAN, NURSE PRACTITIONER OR CDE
SECTION 1: CONTACT INFORMATION - AUTHORIZED PRESCRIBER
PRESCRIBER NAME
SIGNATURE
TELEPHONE
DATE
ONLY MODERATE OR HIGH RISK QUALIFY FOR SERVICES UNDER THIS PROGRAM
PART A
EXAM FINDINGS
R
L
RISK
Intact and Healthy
LOW
Callous/corn
MODERATE
Crack or fissure
SKIN
Blister/Hemorrhagic callous
HIGH
No-infected ulcers or skin breakdown
Infected, draining ulcers
URGENT
Red, hot swollen foot/cellulitis
Normal, well kept, minimal discoloration
LOW
NAILS
MODERATE
Missing, sharp, unkempt, thickened, long or deformed
Infected, ingrown
HIGH
LOW
Normal
Bunion
Hammer or claw toes
Overlapping digits
MODERATE
STRUCTURE
Limited mobility/range of motion at ankle or toe joint
ANATOMY
Fallen Arch
Rocker bottom foot/stable Charcot foot changes
Previous amputation
HIGH
Any of the above abnormalities with redness over pressure areas
URGENT
Red, hot painful joint or acute Charcot joint “collapse”
S
D
OCIAL
EVELOPMENT
DÉVELOPPEMENT SOCIAL
Health Services Program
Programme des services de santé
P.O. Box 5500, Fredericton, NB E3B 5G4
C.P. 5500, Fredericton, NB E3B 5G4
Toll free number: 1-844-551-3015
Numéro sans frais: 1-844-551-3015
Télécopieur: (506) 453-3960
Fax: (506) 453-3960
Clear
Page 1 of 2
SOCIAL ASSISTANCE CLIENTS ONLY
DIABETIC FOOT/NAIL CARE APPLICATION FORM
THE FOLLOWING 5 STEPS MUST BE COMPLETED BEFORE THIS APPLICATION CAN BE PROCESSED:
1. Applicant must complete Client Information Section and provide form to their Physician, Nurse Practitioner or Certified
Diabetic Educator (CDE).
2. Physician, Nurse Practitioner or CDE must fill out Section 1 & Part A & B and return to client.
3. Client must choose Foot/Nail Service Provider and provide them the form.
4. Foot/Nail Care Service Provider must complete Section 2. (Note: Vendor number is required).
5. Completed form to be returned to:
Health Services Program
P.O. Box 5500, Fredericton, NB E3B 5G4
Fax: (506) 453-3960
TO BE COMPLETED BY THE APPLICANT
CLIENT INFORMATION SECTION
LAST NAME
FIRST NAME
DATE OF BIRTH
ADDRESS
CITY, TOWN
POSTAL CODE
S.D. HEALTH CARD #
TELEPHONE
TO BE COMPLETED BY A PHYSICIAN, NURSE PRACTITIONER OR CDE
SECTION 1: CONTACT INFORMATION - AUTHORIZED PRESCRIBER
PRESCRIBER NAME
SIGNATURE
TELEPHONE
DATE
ONLY MODERATE OR HIGH RISK QUALIFY FOR SERVICES UNDER THIS PROGRAM
PART A
EXAM FINDINGS
R
L
RISK
Intact and Healthy
LOW
Callous/corn
MODERATE
Crack or fissure
SKIN
Blister/Hemorrhagic callous
HIGH
No-infected ulcers or skin breakdown
Infected, draining ulcers
URGENT
Red, hot swollen foot/cellulitis
Normal, well kept, minimal discoloration
LOW
NAILS
MODERATE
Missing, sharp, unkempt, thickened, long or deformed
Infected, ingrown
HIGH
LOW
Normal
Bunion
Hammer or claw toes
Overlapping digits
MODERATE
STRUCTURE
Limited mobility/range of motion at ankle or toe joint
ANATOMY
Fallen Arch
Rocker bottom foot/stable Charcot foot changes
Previous amputation
HIGH
Any of the above abnormalities with redness over pressure areas
URGENT
Red, hot painful joint or acute Charcot joint “collapse”
S
D
OCIAL
EVELOPMENT
DÉVELOPPEMENT SOCIAL
Health Services Program
Programme des services de santé
P.O. Box 5500, Fredericton, NB E3B 5G4
C.P. 5500, Fredericton NB, E3B 5G4
Toll free number: 1-844-551-3015
Numéro sans frais: 1-844-551-3015
Fax: (506) 453-3960
Télécopieur: (506) 453-3960
Page 2 of 2
SENSATION
Normal sensation to 10g monofilament exam
LOW
Subjective complaint of numbness, tingling, crawling or burning sensation
MODERATE
Absent sensation to 10 g monofilament exam at one or more sites (callous may give
mark + or –
false negative finding)
for sensation
testing
URGENT
Pain or inflammation in a previously insensate foot
LOW
Normal pulses, Normal capillary refill
Hair loss, spider veins, varicosities
MODERATE
Edema
Leg muscle pain or fatigue on walking that is relieved by rest in minutes-
VASCULAR
Cool skin with pallor or cyanosis
Reduced pulses
HIGH
Dependent rubor
Gangrene
URGENT
Cold white painful foot or toes
Adequate foot care e.g. healthy skin, nails
LOW
FOOT CARE
MODERATE
Inadequate foot care – needs education and/or assistance with foot care
HIGH
Grossly abnormal skin/nail – needs specialty care
LOW
Appropriate to accommodate foot shape
FOOTWEAR
MODERATE
Inappropriate e.g. worn out, too tight, too high
Footwear causing pressure/skin breakdown
HIGH
PART B
TIME FRAME OF MEDICAL ISSUE
Please indicate below if the patient’s functional impairment/ condition(s) is expected to improve.
The client’s foot/nail issue should improve within ________ (timeframe indicated).
The client’s foot/nail issue is not expected to improve.
TO BE COMPLETED BY FOOT / NAIL CARE AUTHORIZED VENDOR
MAXIMUM ALLOWABLE BENEFIT IS $45.00 EVERY 60 DAYS
SECTION 2: FOOT/NAIL CARE AUTHORIZED VENDOR DETAILS
BUSINESS NAME
VENDOR#
ADDRESS
CITY, TOWN
POSTAL CODE
E-MAIL
TELEPHONE
FAX
FOR OFFICE USE ONLY
ADMINISTRATOR
NAME
PHONE
APPROVED DATE
REFUSED DATE SEE COMMENTS
PENDING INFORMATION SEE
BELOW
COMMENTS BELOW
NOTES
Révisé / Revised 2019/05/23
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