General Medical Supplies and Equipment Prior Approval Form

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Section 1: Patient Information

Patient's Surname:
Date of Birth: (DD/MM/YY)
Given Name(s):
Sex: M | F
Band #:
Family #:
Client ID#:

Section 2: Prescriber Information

Prescriber's Name:
License / Billing #:
Telephone #:
Fax #:

Section 3: Client Health Information

Diagnosis:

Explanation of benefit requirement and specific details of item to be provided (MUST BE COMPLETED):

Is the benefit requested due to the result of an injury: Yes | No ~
If yes, please complete the following:

Where did the injury occur: Home | Work | Other

When did the injury occur:

Are any of these expenses covered under any other public or private health care plan: Yes | No

Section 4:Equipment or Supplies Requested

• Description of Device:
• Benefit Code
• Qty
• Cost

Section 5: Provider Information

Provider Name:
Provider #:
Telephone #:
Fax#:

I hereby certify that the information in Sections 4 and 5 is true and complete.
Provider Signature:
Date:

FOR NIHB OFFICE USE ONLY

P. A.#:
User ID#:
Office Telephone #:
Office Fax #: