Social Development
Health Services Program
P.O. Box 5500, Fredericton, N.B., E3B 5G4
Toll fre number: 1-844-551-3015
Fax: (506) 453-3960 / / développement social
Programme des services de santé
C.P. 5500, Fredericton N.-B., E3B 5G4
Numéro sans frais: 1-844-551-3015
Télécopieur: (506) 453-3960

APPLICATION FOR EQUIPMENT MAINTENANCE

HEALTH SERVICES PROGRAM

Part I – to be completed by client:

CLIENT INFORMATION

Name: / Date of Birth
Address: / Telephone:
Health Card # / Medicare #

I am applying for coverage of repairs and modifications for the equipment listed in Part II of this form.

I understand that if this request is approved, repairs and maintenance for the listed equipment will be funded by Social Development provided my Health Card remains active with the proper coverage and I agree to the following terms and conditions:

1.  I confirm that I own this equipment.

2.  I confirm that I have no other equipment that meets this need.

3.  I will care for this equipment as per the instructions received from my therapist and/or service technician.

4.  I will have all repairs and maintenance completed by a certified service technician.

5.  I will operate this equipment safely.

6.  I will not abuse or misuse the equipment in any way.

7.  This agreement will terminate when this equipment is replaced or no longer required.

Signature of client: Date:

OR

Signature of Legal Guardian/: Date:

Relationship to: Witness signature:

Client/ Position

*** If someone other than the client signs this agreement, they are agreeing on the client’s behalf to uphold all terms and conditions mentioned above.

Application for Equipment Maintenance …page 2

Client Name: Health Card Number:

Part II – to be completed by an Occupational Therapist or Physiotherapist:

Type of Equipment & Category: ** / Benefit Item: ** / Make, Model &
Serial #: / Age of Equipment / Purchaser / SD Eligibility Criteria Met

** If the equipment requiring repair or maintenance has options for which SD has established eligibility criteria, please ensure that you include the applicable criteria for these, as well. Please refer to SD Guide for information regarding which options have eligibility criteria attached.

For any equipment that is a Special Authorization benefit, you must complete the following section (similarly to Part D of the ERF) to explain how and why the above mentioned criteria are met.

Justification for Special Authorization benefits:

Application for Equipment Maintenance …page 3

Client Name: Health Card Number:

THERAPIST INFORMATION:

Name: / Telephone:
Mailing:
Address / Email:
Fax Number:
Therapist Signature: