CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE / AUTOMATIC POSITIVE AIRWAY PRESSURE DEVICE (CPAP/APAP) - PURCHASE

GENERAL NOTES PRE-AUTHORIZATION REQUIRED UNLESS OTHERWISE INDICATED. COMMAS APPEARING IN THE "PRESCRIBER REQUIRED" AND "RECOMMENDER REQUIRED" COLUMNS INDICATE OR, EG. "MD", "RN" MEANS MD OR RN. WHERE A REQUIRED PRESCRIPTION IS INDICATED: A CURRENT PRESCRIPTION IS REQUIRED AND BE VALID ONE YEAR AFTER THE DATE WRITTEN. WHERE REGISTERED POLYSOMNOGRAPHIC TECHNOLOGIST (PG), REGISTERED NURSE (RN) OR LICENSED PRACTICAL NURSE (LP)/REGISTERED PRACTICAL NURSE (RO) ARE INDICATED AS A REQUIRED RECOMMENDER, THE RECOMMENDER MUST BE WITHIN THEIR SCOPE OF PRACTICE IN THEIR PROVINCE/TERRITORY. WHERE A REQUIRED RECOMMENDER IS INDICATED, A REPORT MUST BE SUBMITTED AND INCLUDE: A. DIAGNOSIS B. FOR PAP THERAPY: TESTING/TRIAL RESULTS CONFIRMING IMPROVEMENT IN CLIENTS SLEEP CONDITION FOR PAP THERAPY (BASED ON A MINIMUM 30-DAY TRIAL PERIOD) FOR OXYGEN THERAPY: ALL FINDINGS FROM THE RESPIRATORY ASSESSMENT, INCLUDING VITAL SIGNS, INSPECTION FINDINGS, PALPATION FINDINGS, AUSCULTATION FINDINGS, OXYGEN RATE, AND/OR ANY OTHER RELEVANT INFORMATION. C.MODEL TYPE AND QUOTE OF REQUESTED ITEMS D. SIGNATURES WITH DESIGNATION FOR ONGOING RENTAL AGREEMENTS, IF DETERMINED THE EQUIPMENT RENTAL HAS/WILL RESULT IN PAYMENTS EXCEEDING THE PURCHASE PRICE, THE RENTAL AGREEMENT SHOULD, WHERE POSSIBLE AND WHEN DETERMINED APPROPRIATE UNDER THE CIRCUMSTANCES, BE TERMINATED AND THE EQUIPMENT PURCHASED. THE RENTAL FEE OF THE SYSTEM IS TO BE DEDUCTED FROM THE PURCHASE PRICE (IF APPLICABLE). PROVIDERS MUST SUPPLY TRAINING ON THE SAFE USE OF OXYGEN THERAPY AND RESPIRATORY EQUIPMENT AND ENSURE THAT THE CLIENT CONTINUES TO USE THE EQUIPMENT PROPERLY DURING FOLLOW-UP APPOINTMENTS. A BENEFIT NOT LISTED IN THE BENEFIT GRID MAY BE CONSIDERED BY EXCEPTION WITH MEDICAL JUSTIFICATION. SPECIAL NOTES NOTE 12 - FOR REPLACEMENT OF CPAP/APAP AND BIPAP DEVICES PREVIOUSLY COVERED BY VAC, CAF, RCMP OR ANOTHER INSURER AND/OR PROVINCIAL/TERRITORIAL HEALTH CARE PLAN (E.G. PSHCP OR THIRD-PARTY INSURER), ONLY A PRESCRIPTION FROM AN MD OR NP IS REQUIRED. A RECOMMENDATION IS NOT REQUIRED NOTE 15 - FOR INDIVIDUALS COVERED UNDER THE PUBLIC SERVICE HEALTH CARE PLAN (PSHCP) OR THE ONTARIO MINISTRY OF HEALTH - ASSISTIVE DEVICES PROGRAM, AND CO-PAYMENT IS REQUESTED, ONLY THE PROOF OF PAYMENT FROM THE INSURER IS REQUIRED.