addendum for ventilator equipment and supplies application...

5063-67E (2017/06) © Queen's Printer for Ontario, 2017 Disponible en français Page 1 of 2

Ministry of Health and Long-Term Care

Assistive Devices Program (ADP) 5700 Yonge Street, 7th Floor Toronto ON M2M 4K5 Tel: 416-327-8804 Toll-free: 1-800-268-6021 TTY: 416-327-4282 TTY: 1-800-387-5559

Addendum for Ventilator Equipment and Supplies Application Form

To be completed by the prescribing physician to facilitate processing a request for Ventilator Equipment and Supplies.

Section 1 – Applicant’s InformationLast Name First Name Middle Initial

Health Card Number (10 digits) Version

Section 2 – Diagnosis

Neuromuscular Disorders

Amyotrophic lateral sclerosis Muscular Dystrophy (specify)

Diaphragm paralysis Spinal Cord Injury SMA

Chest Wall Deformities

Kyphoscoliosis Other (specify)

Central Respiratory Drive Depression

Drugs - (e.g. Narcotics) Neurological disorders (e.g. Trauma, stroke, multiple sclerosis)

Obesity Hypoventilation Syndrome

Obstructive Sleep Apnea Syndrome (OSAS)

Complicated OSAS CPAP intolerant CPAP-emergent Central apnea

Chronic Obstructive Pulmonary Disease (COPD)

Other (specify)

Section 3 – Equipment Details VentilatorVentilator

Quantity 1 2

Circuit Type Ventilator Settings

Ventilator Interface Mask Mouthpiece Tracheostomy

Bi-Level STBi-level Settings IP EP Rate

Humidifier Yes No Quantity 1 2

Hours of Ventilation/Ventilation Assist < 12 12-24 24

Battery Yes No Charger Yes No Cable Yes No

5063-67E (2017/06) Page 2 of 2

Applicant's Last Name First Name Health Number (10 digits) Version

Mechanical In-Exsufflation

SettingsInsp. Pressure Exp. Pressure

Saturation Monitor (max of 2 years)Start Date (yyyy/mm/dd) End Date (yyyy/mm/dd)

Alarm SettingHigh Sp02 Low Sp02

High HR Low HR

Section 4 – Equipment Delivery Instructions

Deliver to

Client’s Home

Client’s Home AddressUnit Number Street Number Street Name

Lot/Concession/Rural Route City/Town Province Postal Code

Telephone Number

Facility

Facility AddressFacility Name

Unit Number Street Number Street Name

Lot/Concession/Rural Route City/Town Province Postal Code

Facility Contact PersonLast Name First Name

Floor Number Room Number Telephone Numberext.

Email Address

Physician SignaturePhysician Last Name Physician First Name

Physician Signature Date Signed (yyyy/mm/dd)

Addendum for Ventilator Equipment and Supplies Application Form�Section 1 – Applicant’s Information�Section 2 – Diagnosis�Section 3 – Equipment Details�Section 4 – Equipment Delivery Instructions�

5063-67E (2017/06) © Queen's Printer for Ontario, 2017

Disponible en français

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5063-67E (2017/06)

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Government of Ontario

Ministry of Health

and Long-Term Care

Assistive Devices Program (ADP)

5700 Yonge Street, 7th Floor

Toronto ON M2M 4K5

Tel: 416-327-8804

Toll-free: 1-800-268-6021

TTY: 416-327-4282

TTY: 1-800-387-5559


Section 1 – Applicant’s Information

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To be completed by the prescribing physician to facilitate processing a request for Ventilator Equipment and Supplies.

Section 1 – Applicant’s Information


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Section 3 – Equipment Details

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Section 3 – Equipment Details

Ventilator

Quantity

Ventilator Interface

Bi-Level ST

Bi-level Settings

Humidifier

Quantity

Hours of Ventilation/Ventilation Assist

Battery

Charger

Cable

Mechanical In-Exsufflation

Settings

Saturation Monitor (max of 2 years)

Alarm Setting


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Deliver to

Client’s Home Address

Facility Address

Facility Contact Person

Physician Signature

8.0.1291.1.339988.308172

Ministry of Health and Long-Term Care


CurrentPageNumber: NumberofPages: Section 4. Facility Contact Person. Last Name.: Section 4. Facility Contact Person. First Name.: Section 1. Health Card Number (10 digits): Section 1. Health Card Version.: TextField1: Section 1. Middle Initial: Section 2 – Diagnosis. Neuromuscular Disorders.: Section 2. Neuromuscular Disorders. Amyotrophic lateral sclerosis.: Section 2. Neuromuscular Disorders. Muscular Dystrophy. : Section 2. Other. specify.: Section 2. Neuromuscular Disorders. Diaphragm paralysis: Section 2. Neuromuscular Disorders. Spinal Cord Injury. : Section 2. Neuromuscular Disorders. SMA.: Section 2. Chest Wall Deformities.: Section 2. Chest Wall Deformities. Kyphoscoliosis. : Section 2. Other.: Section 2. Central Respiratory drive depression. : Section 2. Central Respiratory drive depression. Drugs - (e.g. Narcotics). : Section 2. Central Respiratory drive depression. Neurological disorders (e.g. Trauma, stroke, multiple sclerosis).: Section 2. Obesity hypoventilation syndrome.: Section 2. Obstructive Sleep Apnea Syndrome (OSAS).: Section 2. Obstructive Sleep Apnea Syndrome (OSAS). Complicated OSAS.: Section 2. Obstructive Sleep Apnea Syndrome (OSAS). CPAP intolerant.: Section 2. Obstructive Sleep Apnea Syndrome (OSAS). CPAP-emergent Central apnea.: Section 2. Chronic Obstructive Pulmonary Disease (COPD).: Section 3. Equipment Details. Ventilator. : Section 3. Bi-Level ST. Quantity. 1.: Section 3. Bi-Level ST. Quantity. 2.: Section 3. Ventilator. Circuit Type.: Section 3. Ventilator. Ventilator Settings.: Section 3. Ventilator. Ventilator Interface. Mask.: Section 3. Ventilator. Ventilator Interface. Mouthpiece.: Section 3. Ventilator. Ventilator Interface. Tracheostomy.: Section 3. Bi-Level ST. Bi-level Settings. IP.: Section 3. Bi-Level ST. Bi-level Settings. EP.: Section 3. Bi-Level ST. Bi-level Settings. Rate.: Section 3. Bi-Level ST. Cable. Yes.: Section 3. Bi-Level ST. Cable. No.: Section 3. Bi-Level ST. Hours of Ventilation/Ventilation Assist. Less than 12.: Section 3. Bi-Level ST. Hours of Ventilation/Ventilation Assist. Between 12 and 24: Section 3. Bi-Level ST. Hours of Ventilation/Ventilation Assist. 24: Section 3. Mechanical In-Exsufflation. Settings. Insp. Pressure.: Section 3. Mechanical In-Exsufflation. Settings. Exp. Pressure: Section 3. Saturation Monitor. Start Date. Enter date in format: year: 4 digits, month: 2 digits, day: 2 digits or select date from the drop down calendar.: Section 3. Saturation Monitor. End Date. Enter date in format: year: 4 digits, month: 2 digits, day: 2 digits or select date from the drop down calendar.: Section 3. Saturation Monitor. Alarm Setting. High Sp02.: Section 3. Saturation Monitor. Alarm Setting. Low Sp02.: Section 3. Saturation Monitor. Alarm Setting. High HR.: Section 3. Saturation Monitor. Alarm Setting. Low HR.: Section 4. Equipment Delivery Instructions. Deliver to. Client’s home.: Section 4. Facility Address. Unit Number.: Section 4. Facility Address. Street Number.: Section 4. Facility Address. Street Name.: Section 4. Facility Address. Lot/Concession/Rural Route.: Section 4. Facility Address. City/Town.: Section 4. Facility Address. Province.: Section 4. Facility Address. Postal Code. Enter Postal Code in format: letter, digit, letter, digit, letter, digit.: Section 4. Facility Contact Person. Telephone Number.: Section 4. Equipment Delivery Instructions. Deliver to. Facility.: Section 4. Facility Address. Facility Name.: Section 4. Facility Contact Person. Floor Number.: Section 4. Facility Contact Person. Room Number.: Section 4. Facility Contact Person. Telephone Number, extension.: Section 4. Facility Contact Person. Email Address.: Section 4. Physician Signature. Physician Last Name. : Section 4. Physician Signature. Physician First Name. : Section 4. Physician Signature.: Section 4. Physician Signature. Date Signed. Enter date in format: year: 4 digits, month: 2 digits, day: 2 digits. : Save Form: Print Form: Clear Form:

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