{"text_format":"1","workbook":"xlsx","n_sheets":10,"sheets":["Cover","A-1","A-2","A-3","A-4","B-C","D","BADD","BALU","CoverDD"],"not_rendered":{"charts":0,"images":22,"macros":1,"external_links":0,"defined_names":34,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"Cover","index":0,"n_rows":43,"n_cols":58,"rows_kept":43,"cut":false,"hidden":false,"merged":[[19,28,19,38],[20,28,20,38],[14,0,14,55],[9,40,9,55],[10,40,10,55],[11,40,11,55],[12,40,12,55],[9,28,9,39],[10,28,10,39],[11,28,11,39],[12,28,12,39],[10,0,10,8],[11,0,11,8],[12,0,12,8],[9,9,9,27],[10,9,10,27],[0,0,3,21],[5,0,5,55],[6,0,6,55],[8,0,8,55],[0,52,1,56],[0,36,3,51],[11,9,11,27],[9,0,9,8],[12,9,12,27],[18,7,18,27],[18,40,18,43],[18,28,18,39],[15,0,16,6],[15,7,16,27],[17,0,17,6],[17,7,17,27],[15,28,15,39],[16,40,16,43],[16,28,16,39],[15,40,15,43],[17,40,17,43],[17,28,17,39],[22,0,22,55],[23,0,23,9],[23,10,23,17],[15,44,15,49],[15,50,15,55],[16,44,16,49],[16,50,16,55],[20,39,20,55],[19,39,19,55],[17,44,17,49],[17,50,17,55],[19,0,20,6],[19,7,20,27],[18,44,18,49],[18,50,18,55],[18,0,18,6],[24,0,24,9],[24,10,24,17],[24,19,24,30],[23,19,23,30],[23,31,23,55],[24,31,24,55],[32,3,32,29],[34,3,34,29],[32,33,32,51],[33,33,33,36],[25,0,28,9],[30,0,30,55],[28,37,28,54],[25,10,25,36],[26,10,26,36],[27,10,27,36],[28,10,28,36],[25,37,25,54],[26,37,26,54],[27,37,27,54],[42,27,42,30],[33,37,33,54],[36,0,36,55],[42,31,42,54],[38,3,38,54],[39,3,39,23],[40,3,40,23],[41,3,41,23],[42,3,42,23],[39,27,39,53],[40,27,40,53],[41,27,41,53],[33,3,33,29],[39,24,39,25]]}
["SOCIAL DEVELOPMENT\nHealth Services Program\nP.O. Box 5500, Fredericton, N.B., E3B 5G4\nToll free number: 1-844-551-3015\nFax: (506) 453-3960",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DÉVELOPPEMENT SOCIAL\nProgramme des services de santé\nC.P. 5500, Fredericton N.-B., E3B 5G4\nNuméro sans frais: 1-844-551-3015\nTélécopieur: (506) 453-3960",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"H16","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"H18","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"K24","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"AL26","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"AL27","v":0}]
["MOBILITY AND ADAPTIVE EQUIPMENT LOAN PROGRAM",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0]
["BASIC ADAPTIVE AIDS EQUIPMENT REQUEST FORM",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0]
[]
["THERAPIST INFORMATION"]
["Date:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Number of pages:"]
["Therapist name:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Phone:"]
["Email:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Fax: "]
["Agency / Office:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Alternate contact name:"]
[]
["CLIENT INFORMATION"]
["Client name:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Date of birth:"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DD",null,null,null,"MM",null,null,null,null,null,"YYYY"]
["Health card #:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health card expiry date:"]
["Medicare #:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DD",null,null,null,"MM",null,null,null,null,null,"YYYY"]
["Complete address:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Phone:"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Language of choice:"]
[]
["REQUEST DETAILS"]
["Request status:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Reason for referral:"]
["Urgent request:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"If yes, indicate reason:"]
["Type of equipment request:",null,null,null,null,null,null,null,null,null,"Part A-1 – Application for Equipment Loan"]
[null,null,null,null,null,null,null,null,null,null,"Part A-2 – Application for Cost Sharing"]
[null,null,null,null,null,null,null,null,null,null,"Part A-3 – Application for Equipment Maintenance"]
[null,null,null,null,null,null,null,null,null,null,"Part A-4 – Application for Purchase of Trial Equipment"]
[]
["DOCUMENTATION INCLUDED"]
[]
[null,null,null,"Part D (exceptions only)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Installation diagram (where applicable)"]
[null,null,null,"Landlord's letter of permission to install (rental units only)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Other: "]
[null,null,null,"Private insurance predetermination letter"]
[]
["THERAPIST'S INSTRUCTIONS FOR SUPPLIER"]
[]
[null,null,null,"Fax Basic Equipment Request Form, quote (E-form) and MSRP to Health Services (506) 453-3960"]
[null,null,null,"Fax copy of quote and MSRP to the therapist",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Contact therapist if MSRP is over the max price"]
[null,null,null,"Deliver the equipment directly to the client",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Supplier to install equipment (permanent installation only)"]
[null,null,null,"Contact therapist for delivery",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Therapist / Landlord to install equipment"]
[null,null,null,"Deliver to therapist's office",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Other: "]

{"sheet":"A-1","index":1,"n_rows":146,"n_cols":58,"rows_kept":146,"cut":false,"hidden":true,"merged":[[129,0,130,11],[129,12,130,55],[131,2,131,11],[131,46,131,55],[122,0,122,11],[122,12,123,33],[122,34,123,50],[122,51,123,55],[123,0,123,11],[124,0,128,11],[124,12,124,30],[124,31,124,43],[124,44,124,55],[125,12,125,30],[125,31,125,43],[125,44,125,54],[126,12,126,30],[126,31,126,43],[126,44,126,54],[127,12,127,30],[127,31,127,43],[127,44,127,54],[128,12,128,30],[128,31,128,43],[128,44,128,54],[115,37,115,55],[116,0,116,4],[116,5,116,24],[116,25,116,36],[116,37,116,55],[117,0,121,11],[117,12,117,33],[117,34,121,50],[117,51,121,55],[118,12,118,33],[119,12,119,33],[120,12,120,33],[121,12,121,33],[104,0,104,11],[97,0,97,4],[97,5,97,24],[97,25,97,36],[97,37,97,55],[98,0,102,11],[98,12,98,33],[98,34,102,50],[98,51,102,55],[99,12,99,33],[100,12,100,33],[101,12,101,33],[102,12,102,33],[103,0,103,11],[103,12,104,33],[134,0,134,55],[136,3,138,54],[139,3,141,54],[110,0,111,11],[110,12,111,55],[112,2,112,11],[105,0,109,11],[105,12,105,30],[105,31,105,43],[105,44,105,55],[106,31,106,43],[106,44,106,54],[107,31,107,43],[107,44,107,54],[108,31,108,43],[108,44,108,54],[109,31,109,43],[109,44,109,54],[107,12,107,30],[108,12,108,30],[114,45,114,54],[115,0,115,11],[115,12,115,24],[115,25,115,36],[90,0,92,11],[90,12,92,55],[96,0,96,11],[96,12,96,24],[96,25,96,36],[96,37,96,55],[85,0,89,11],[85,12,85,30],[85,31,85,43],[85,44,85,55],[86,31,86,43],[86,44,86,54],[87,31,87,43],[87,44,87,54],[88,31,88,43],[88,44,88,54],[89,31,89,43],[89,44,89,54],[93,45,93,54],[95,45,95,54],[93,1,93,10],[83,0,83,11],[83,12,84,33],[83,34,84,50],[83,51,84,55],[84,0,84,11],[77,0,77,4],[77,5,77,24],[77,25,77,36],[77,37,77,55],[78,0,82,11],[78,12,78,33],[78,34,82,50],[78,51,82,55],[79,12,79,33],[80,12,80,33],[81,12,81,33],[82,12,82,33],[70,0,72,11],[70,12,72,55],[73,2,73,11],[76,0,76,11],[76,12,76,24],[76,25,76,36],[76,37,76,55],[65,0,69,11],[65,12,65,30],[65,31,65,43],[65,44,65,55],[66,31,66,43],[66,44,66,54],[67,31,67,43],[67,44,67,54],[68,31,68,43],[68,44,68,54],[69,31,69,43],[69,44,69,54],[73,46,73,55],[63,0,63,11],[63,12,64,33],[63,34,64,50],[63,51,64,55],[64,0,64,11],[57,0,57,4],[57,5,57,24],[57,25,57,36],[57,37,57,55],[58,0,62,11],[58,12,58,33],[58,34,62,50],[58,51,62,55],[59,12,59,33],[60,12,60,33],[61,12,61,33],[62,12,62,33],[46,1,46,10],[56,0,56,11],[56,12,56,24],[56,25,56,36],[56,37,56,55],[42,31,42,43],[42,44,42,54],[43,0,45,11],[43,12,45,55],[55,0,55,11],[46,46,46,55],[29,12,29,24],[29,25,29,36],[36,34,37,50],[36,51,37,55],[37,0,37,11],[38,0,42,11],[38,12,38,30],[38,31,38,43],[38,44,38,55],[39,31,39,43],[39,44,39,54],[40,31,40,43],[40,44,40,54],[41,31,41,43],[41,44,41,54],[39,12,39,30],[40,12,40,30],[41,12,41,30],[42,12,42,30],[9,5,9,24],[9,0,9,4],[0,57,0,81],[1,57,1,81],[0,0,3,21],[5,0,5,55],[0,53,1,56],[0,36,3,52],[4,7,4,26],[4,0,4,6],[4,28,4,38],[4,39,4,55],[6,0,6,55],[8,0,8,11],[8,12,8,24],[8,25,8,36],[9,25,9,36],[8,37,8,55],[9,37,9,55],[2,57,2,76],[3,57,3,63],[12,12,12,33],[13,12,13,33],[14,12,14,33],[10,34,14,50],[10,51,14,55],[15,0,15,11],[16,0,16,11],[15,12,16,33],[15,34,16,50],[15,51,16,55],[10,0,14,11],[11,12,11,33],[10,12,10,33],[17,0,21,11],[17,12,17,30],[18,31,18,43],[17,31,17,43],[17,44,17,55],[19,31,19,43],[20,31,20,43],[21,31,21,43],[18,44,18,54],[19,44,19,54],[20,44,20,54],[21,44,21,54],[18,12,18,30],[19,12,19,30],[20,12,20,30],[21,12,21,30],[142,3,144,27],[142,31,144,54],[22,0,24,11],[22,12,24,55],[26,2,26,11],[30,0,30,4],[30,5,30,24],[30,25,30,36],[30,37,30,55],[31,0,35,11],[31,12,31,33],[31,34,35,50],[31,51,35,55],[29,37,29,55],[25,46,25,55],[32,12,32,33],[33,12,33,33],[34,12,34,33],[35,12,35,33],[28,0,28,11],[25,2,25,11],[36,0,36,11],[36,12,37,33],[29,0,29,11],[112,46,112,55],[109,12,109,30],[66,12,66,30],[67,12,67,30],[68,12,68,30],[69,12,69,30],[86,12,86,30],[87,12,87,30],[88,12,88,30],[89,12,89,30],[106,12,106,30],[103,34,104,50],[103,51,104,55]]}
["SOCIAL DEVELOPMENT\nHealth Services Program\nP.O. Box 5500, Fredericton, N.B., E3B 5G4\nToll Free Number: 1-844-551-3015\nFax: (506) 453-3960",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DÉVELOPPEMENT SOCIAL\nProgramme des services de santé\nC.P. 5500, Fredericton N.-B., E3B 5G4\nNuméro sans frais: 1-844-551-3015\nTélécopieur: (506) 453-3960",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H16","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H18","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!K24","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!AL26","v":0}]
["Client Name: ",null,null,null,null,null,null,{"$f":"Cover!H16","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card ID: ",null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H18","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!AL27","v":0}]
["MOBILITY AND ADAPTIVE EQUIPMENT LOAN PROGRAM",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!AL28","v":0}]
["PART A-1 APPLICATION FOR EQUIPMENT LOAN",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!AL29","v":0}]
["REQUEST #1"]
["Type of equipment:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Category:"]
["Benefit: ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Make, model and size:"]
["Reason for request:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Does the client meet ALL eligibility criteria? \n\n(Refer to MAELP guide)"]
[]
[]
[]
[]
["Location of installation",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Permanent installation by the supplier?"]
["(Transfer aids only)"]
["Options / Additional Services\n\n(Where applicable only, \nsee MAELP guide.)",null,null,null,null,null,null,null,null,null,null,null,"Category",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Benefit",null,null,null,null,null,null,null,null,null,null,null,null,"ALL eligibility criteria met? (See MAELP guide)"]
[]
[]
[]
[]
["Additional information / Specifications:"]
[]
[]
[null,"*","Part D required"]
[]
[]
["REQUEST #2"]
["Type of equipment:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Category:",null,null,null,null,null,null,null,null,null,null,null,"Please select..."]
["Benefit: ",null,null,null,null,"Select after category...",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Make, model and size:"]
["Reason for request:",null,null,null,null,null,null,null,null,null,null,null,"New request",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Does the client meet ALL eligibility criteria? \n\n(Refer to MAELP guide)"]
[]
[]
[]
[]
["Location of installation",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Permanent installation by the supplier?"]
["(Transfer aids only)"]
["Options / Additional Services\n\n(Where applicable only, \nsee MAELP guide.)",null,null,null,null,null,null,null,null,null,null,null,"Category",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Benefit",null,null,null,null,null,null,null,null,null,null,null,null,"ALL eligibility criteria met? (See MAELP guide)"]
[null,null,null,null,null,null,null,null,null,null,null,null,"Basic Ambulation Aid Options",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Please select..."]
[]
[]
[]
["Additional information / Specifications:"]
[]
[]
["*","Part D required"]
[]
[]
[]
[]
[]
[]
[]
[]
["REQUEST #3"]
["Type of equipment:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Category:"]
["Benefit: ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Make, model and size:"]
["Reason for request:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Does the client meet ALL eligibility criteria? \n\n(Refer to MAELP guide)"]
[]
[]
[]
[]
["Location of installation",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Permanent installation by the supplier?"]
["(Transfer aids only)"]
["Options / Additional Services\n\n(Where applicable only, \nsee MAELP guide.)",null,null,null,null,null,null,null,null,null,null,null,"Category",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Benefit",null,null,null,null,null,null,null,null,null,null,null,null,"ALL eligibility criteria met? (See MAELP guide)"]
[null,null,null,null,null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[null,null,null,null,null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[null,null,null,null,null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[null,null,null,null,null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional information / Specifications:"]
[]
[]
[null,"*","Part D required"]
[]
["REQUEST #4"]
["Type of equipment:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Category:"]
["Benefit: ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Make, model and size:"]
["Reason for request:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Does the client meet ALL eligibility criteria? \n\n(Refer to MAELP guide)"]
[]
[]
[]
[]
["Location of installation",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Permanent installation by the supplier?"]
["(Transfer aids only)"]
["Options / Additional Services\n\n(Where applicable only, \nsee MAELP guide.)",null,null,null,null,null,null,null,null,null,null,null,"Category",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Benefit",null,null,null,null,null,null,null,null,null,null,null,null,"ALL eligibility criteria met? (See MAELP guide)"]
[]
[]
[]
[]
["Additional information / Specifications:"]
[]
[]
["*","Part D required"]
[]
["REQUEST #5"]
["Type of equipment:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Category:"]
["Benefit: ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Make, model and size:"]
["Reason for request:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Does the client meet ALL eligibility criteria? \n\n(Refer to MAELP guide)"]
[]
[]
[]
[]
["Location of installation",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Permanent installation by the supplier?"]
["(Transfer aids only)"]
["Options / Additional Services\n\n(Where applicable only, \nsee MAELP guide.)",null,null,null,null,null,null,null,null,null,null,null,"Category",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Benefit",null,null,null,null,null,null,null,null,null,null,null,null,"ALL eligibility criteria met? (See MAELP guide)"]
[]
[]
[]
[]
["Additional information / Specifications:"]
[]
[null,"*","Part D required"]
[]
["REQUEST #6"]
["Type of equipment:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Category:"]
["Benefit: ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Make, model and size:"]
["Reason for request:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Does the client meet ALL eligibility criteria? \n\n(Refer to MAELP guide)"]
[]
[]
[]
[]
["Location of installation",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Permanent installation by the supplier?"]
["(Transfer aids only)"]
["Options / Additional Services\n\n(Where applicable only, \nsee MAELP guide.)",null,null,null,null,null,null,null,null,null,null,null,"Category",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Benefit",null,null,null,null,null,null,null,null,null,null,null,null,"ALL eligibility criteria met? (See MAELP guide)"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[]
[null,null,null,null,null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional information / Specifications:"]
[]
[null,"*","Part D required"]
[]
[]
["THERAPIST'S SIGNATURE"]
[]
[null,null,null,"I understand that if a trial is not completed and the equipment purchased does not end up working for the client, Health Services may not consider the provision of additional equipment to meet the same need. "]
[]
[]
[null,null,null,"I confirm that the assessment for this client is complete and that this is the final request for equipment to meet this client's adaptive equipment needs. "]
[]
[]
[]
[]
[]
[null,null,null,"Therapist's name",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Date"]

{"sheet":"A-2","index":2,"n_rows":138,"n_cols":58,"rows_kept":138,"cut":false,"hidden":true,"merged":[[121,0,122,11],[121,12,122,55],[123,45,123,55],[126,0,126,55],[128,3,130,54],[131,3,133,54],[114,51,115,55],[115,0,115,11],[116,0,120,11],[116,12,116,30],[116,31,116,43],[116,44,116,55],[117,31,117,43],[117,44,117,54],[118,31,118,43],[118,44,118,54],[119,31,119,43],[119,44,119,54],[118,12,118,30],[119,12,119,30],[120,12,120,30],[79,0,79,11],[106,0,106,11],[107,0,107,11],[107,12,107,24],[107,25,107,36],[107,37,107,55],[77,45,77,55],[80,0,80,11],[80,12,80,24],[80,25,80,36],[80,37,80,55],[87,0,87,11],[87,12,88,33],[87,34,88,50],[87,51,88,55],[88,0,88,11],[81,0,81,5],[81,6,81,24],[81,25,81,36],[81,37,81,55],[82,0,86,11],[82,12,82,33],[82,34,86,50],[82,51,86,55],[0,0,3,21],[5,0,5,55],[6,0,6,55],[0,57,0,81],[1,57,1,81],[0,53,1,56],[0,36,3,52],[4,0,4,6],[4,7,4,26],[4,28,4,38],[4,39,4,55],[20,34,21,44],[22,34,23,44],[20,11,21,33],[22,11,23,33],[8,0,12,55],[16,0,18,55],[20,0,21,10],[20,45,21,55],[14,21,14,27],[39,0,41,55],[22,45,23,55],[25,0,29,55],[30,0,32,55],[22,0,23,10],[33,5,33,52],[35,5,35,52],[36,5,36,52],[37,5,37,52],[34,5,34,56],[50,0,53,55],[54,0,57,21],[54,36,57,56],[59,0,59,55],[61,0,61,11],[61,12,61,24],[61,25,61,36],[61,37,61,55],[58,0,58,6],[58,7,58,26],[58,28,58,38],[58,39,58,55],[63,12,63,33],[63,34,67,50],[63,51,67,55],[64,12,64,33],[65,12,65,33],[66,12,66,33],[67,12,67,33],[62,0,62,5],[62,6,62,24],[62,25,62,36],[62,37,62,55],[63,0,67,11],[68,34,69,50],[70,0,74,11],[75,0,76,11],[75,12,76,55],[74,31,74,43],[74,44,74,54],[68,51,69,55],[69,0,69,11],[68,0,68,11],[68,12,69,33],[70,12,70,30],[70,31,70,43],[70,44,70,55],[71,31,71,43],[71,44,71,54],[72,31,72,43],[72,44,72,54],[73,31,73,43],[73,44,73,54],[71,12,71,30],[72,12,72,30],[73,12,73,30],[74,12,74,30],[134,3,136,27],[134,31,136,54],[83,12,83,33],[84,12,84,33],[85,12,85,33],[86,12,86,33],[94,0,95,11],[94,12,95,55],[96,45,96,55],[89,0,93,11],[89,12,89,30],[89,31,89,43],[89,44,89,55],[90,31,90,43],[90,44,90,54],[91,31,91,43],[91,44,91,54],[92,31,92,43],[92,44,92,54],[93,31,93,43],[93,44,93,54],[120,31,120,43],[120,44,120,54],[108,0,108,5],[90,12,90,30],[91,12,91,30],[92,12,92,30],[93,12,93,30],[117,12,117,30],[108,6,108,24],[108,25,108,36],[114,0,114,11],[114,12,115,33],[114,34,115,50],[108,37,108,55],[109,0,113,11],[109,12,109,33],[109,34,113,50],[109,51,113,55],[110,12,110,33],[111,12,111,33],[112,12,112,33],[113,12,113,33]]}
["SOCIAL DEVELOPMENT\nHealth Services Program\nP.O. Box 5500, Fredericton, N.B., E3B 5G4\nToll Free Number: 1-844-551-3015\nFax: (506) 453-3960",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DÉVELOPPEMENT SOCIAL\nProgramme des services de santé\nC.P. 5500, Fredericton N.-B., E3B 5G4\nNuméro sans frais: 1-844-551-3015\nTélécopieur: (506) 453-3960",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H16","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H18","v":0}]
[]
[]
["Client Name: ",null,null,null,null,null,null,{"$f":"Cover!H16","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card ID: ",null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H18","v":0}]
["MOBILITY AND ADAPTIVE EQUIPMENT LOAN PROGRAM"]
["PART A-2 APPLICATION FOR COST SHARING"]
[]
["• Please refer to the Health Services Cost Sharing Procedures and the Health Services Cost Sharing Policy before completing this application. \n\n• Any requests for FSCD program, children (600#'s) whose families have private insurance, MUST be submitted to the child's social worker for financial approval before Health Services is able to process the request."]
[]
[]
[]
[]
[]
["Part I - To be completed by the client"]
[]
["I am requesting assistance from the Health Services Program to obtain the equipment indicated in this request. I have enclosed a copy of the Pre-determination letter from the other insuring agency indicating their pre-approval and I am requesting coverage of the balance of the cost. "]
[]
[]
[]
["Equipment:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Total cost: "]
[]
["Other insuring agency:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Amount of their pre-approval:"]
[]
[]
["I understand that if the Health Services Program agrees to cost share on the purchase of this equipment, that I will own the equipment UNLESS the amount requested from the Program is 50% or more of the cost of each piece of equipment. In these instances, ownership of any equipment that is recyclable will be transferred to the Mobility and Adaptive Equipment Loan Program."]
[]
[]
[]
[]
["I agree to the following terms and conditions: "]
[]
[]
[null,null,null,"•",null,"I agree to care for this equipment as instructed"]
[null,null,null,"•",null,"I will have all repairs and maintenance completed by a supplier that is currently under contract with Social Development"]
[null,null,null,"•",null,"I agree to operate this equipment safely."]
[null,null,null,"•",null,"I agree not to abuse or misuse this equipment"]
[]
[]
["I am aware that repairs and maintenance will be eligible for payment through the Health Services Program so long as my Health Card remains active and has the appropriate coverage for these services."]
[]
[]
[]
[]
["Client signature",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Witness"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"OR"]
[]
[]
["Legal guardian's signature *",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Date"]
[]
["* 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. "]
[]
[]
[]
["SOCIAL DEVELOPMENT\nHealth Services Program\nP.O. Box 5500, Fredericton, N.B., E3B 5G4\nToll Free Number: 1-844-551-3015\nFax: (506) 453-3960",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DÉVELOPPEMENT SOCIAL\nProgramme des services de santé\nC.P. 5500, Fredericton N.-B., E3B 5G4\nNuméro sans frais: 1-844-551-3015\nTélécopieur: (506) 453-3960"]
[]
[]
[]
["Client Name: ",null,null,null,null,null,null,{"$f":"Cover!H16","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card ID: ",null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H18","v":0}]
["Part II - To be completed by an Occupational Therapist or Physiotherapist:"]
["REQUEST #1"]
["Type of equipment:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Category:"]
["Benefit: ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Make, model and size:"]
["Reason for request:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Does the client meet ALL eligibility criteria? \n\n(Refer to MAELP guide)"]
[]
[]
[]
[]
["Location of installation",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Permanent installation by the supplier?"]
["(Transfer aids only)"]
["Options / Additional Services\n\n(Where applicable only, \nsee MAELP guide.)",null,null,null,null,null,null,null,null,null,null,null,"Category",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Benefit",null,null,null,null,null,null,null,null,null,null,null,null,"ALL eligibility criteria met? (See MAELP guide)"]
[null,null,null,null,null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[null,null,null,null,null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[null,null,null,null,null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[null,null,null,null,null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional information / Specifications:"]
[]
["*","Part D required"]
[]
["REQUEST #2"]
["Type of equipment:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Category:"]
["Benefit: ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Make, model and size:"]
["Reason for request:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Does the client meet ALL eligibility criteria? \n\n(Refer to MAELP guide)"]
[]
[]
[]
[]
["Location of installation",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Permanent installation by the supplier?"]
["(Transfer aids only)"]
["Options / Additional Services\n\n(Where applicable only, \nsee MAELP guide.)",null,null,null,null,null,null,null,null,null,null,null,"Category",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Benefit",null,null,null,null,null,null,null,null,null,null,null,null,"ALL eligibility criteria met? (See MAELP guide)"]
[]
[]
[]
[]
["Additional information / Specifications:"]
[]
["*","Part D required"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["REQUEST #3"]
["Type of equipment:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Category:"]
["Benefit: ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Make, model and size:"]
["Reason for request:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Does the client meet ALL eligibility criteria? \n\n(Refer to MAELP guide)"]
[]
[]
[]
[]
["Location of installation",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Permanent installation by the supplier?"]
["(Transfer aids only)"]
["Options / Additional Services\n\n(Where applicable only, \nsee MAELP guide.)",null,null,null,null,null,null,null,null,null,null,null,"Category",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Benefit",null,null,null,null,null,null,null,null,null,null,null,null,"ALL eligibility criteria met? (See MAELP guide)"]
[]
[]
[]
[]
["Additional information / Specifications:"]
[]
["*","Part D required"]
[]
[]
["THERAPIST'S SIGNATURE"]
[]
[null,null,null,"I understand that if a trial is not completed and the equipment purchased does not end up working for the client, Health Services may not consider the provision of additional equipment to meet the same need. "]
[]
[]
[null,null,null,"I confirm that the assessment for this client is complete and that this is the final request for equipment to meet this client's adaptive equipment needs. "]
[]
[]
[]
[]
[]
[null,null,null,"Therapist's name",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Date"]

{"sheet":"A-3","index":3,"n_rows":135,"n_cols":58,"rows_kept":135,"cut":false,"hidden":true,"merged":[[123,0,124,11],[123,12,124,55],[125,45,125,55],[127,0,127,55],[129,3,131,54],[118,0,122,11],[118,12,118,30],[118,31,118,43],[118,44,118,55],[119,31,119,43],[119,44,119,54],[120,31,120,43],[120,44,120,54],[121,31,121,43],[121,44,121,54],[122,31,122,43],[122,44,122,54],[116,0,116,11],[116,12,117,33],[116,34,117,50],[116,51,117,55],[117,0,117,11],[110,0,110,5],[110,6,110,24],[110,25,110,36],[110,37,110,55],[111,0,115,11],[111,12,111,33],[111,34,115,50],[111,51,115,55],[112,12,112,33],[113,12,113,33],[114,12,114,33],[115,12,115,33],[103,0,104,11],[103,12,104,55],[105,45,105,55],[109,0,109,11],[109,12,109,24],[109,25,109,36],[109,37,109,55],[98,0,102,11],[98,12,98,30],[98,31,98,43],[98,44,98,55],[99,31,99,43],[99,44,99,54],[100,31,100,43],[100,44,100,54],[101,31,101,43],[101,44,101,54],[102,31,102,43],[102,44,102,54],[96,0,96,11],[96,12,97,33],[96,34,97,50],[96,51,97,55],[97,0,97,11],[90,0,90,5],[90,6,90,24],[90,25,90,36],[90,37,90,55],[91,0,95,11],[91,12,91,33],[91,34,95,50],[91,51,95,55],[92,12,92,33],[93,12,93,33],[94,12,94,33],[95,12,95,33],[86,45,86,55],[89,0,89,11],[89,12,89,24],[89,25,89,36],[89,37,89,55],[71,0,71,5],[71,6,71,24],[4,7,4,26],[4,28,4,38],[4,39,4,55],[58,0,58,6],[58,7,58,26],[58,28,58,38],[58,39,58,55],[71,25,71,36],[71,37,71,55],[39,0,41,55],[54,0,57,21],[54,36,57,56],[59,0,59,55],[61,3,62,55],[64,3,66,55],[70,0,70,11],[70,12,70,24],[0,57,0,81],[1,57,1,81],[26,5,27,55],[0,0,3,21],[5,0,5,55],[6,0,6,55],[8,0,9,55],[13,0,15,55],[16,0,20,55],[24,5,25,55],[22,5,22,55],[23,5,23,55],[0,54,1,56],[0,36,3,53],[4,0,4,6],[11,21,11,26],[70,25,70,36],[70,37,70,55],[72,0,76,11],[72,12,72,33],[72,34,76,50],[72,51,76,55],[73,12,73,33],[74,12,74,33],[75,12,75,33],[76,12,76,33],[132,3,133,27],[132,31,133,54],[77,34,78,50],[77,51,78,55],[78,0,78,11],[77,0,77,11],[77,12,78,33],[79,12,79,30],[79,31,79,43],[79,44,79,55],[84,0,85,11],[84,12,85,55],[83,31,83,43],[83,44,83,54],[79,0,83,11],[80,31,80,43],[80,44,80,54],[81,31,81,43],[81,44,81,54],[82,31,82,43],[82,44,82,54],[80,12,80,30],[81,12,81,30],[82,12,82,30],[83,12,83,30],[99,12,99,30],[100,12,100,30],[101,12,101,30],[102,12,102,30],[119,12,119,30],[120,12,120,30],[121,12,121,30],[122,12,122,30]]}
["SOCIAL DEVELOPMENT\nHealth Services Program\nP.O. Box 5500, Fredericton, N.B., E3B 5G4\nToll Free Number: 1-844-551-3015\nFax: (506) 453-3960",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DÉVELOPPEMENT SOCIAL\nProgramme des services de santé\nC.P. 5500, Fredericton N.-B., E3B 5G4\nNuméro sans frais: 1-844-551-3015\nTélécopieur: (506) 453-3960",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H16","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H18","v":0}]
[]
[]
["Client Name: ",null,null,null,null,null,null,{"$f":"Cover!H16","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card ID: ",null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H18","v":0}]
["MOBILITY AND ADAPTIVE EQUIPMENT LOAN PROGRAM"]
["PART A-3 APPLICATION FOR EQUIPMENT MAINTENANCE"]
[]
["***Please refer to the Equipment Maintenance Policy & Procedures before completing this form. ***"]
[]
[]
["Part I - To be completed by the client"]
[]
["I am applying for coverage of current or future repairs, modifications, and/or the provision of additional related components for equipment which was not provided to me through the Health Services Program and is listed in Part II of this form. "]
[]
[]
["I understand that all equipment listed in Part II of this application may not be approved for maintenance and that my Therapist will be provided with an email specifying the equipment and/or components that have been approved for coverage. With this approval, I understand that repairs, maintenance and/or provisions of additional related equipment or components will only be eligible for approval as long as my Health Card remains active with the proper coverage and I agree to the following terms and conditions: "]
[]
[]
[]
[]
[]
[null,null,null,"•",null,"I confirm that I own this equipment. "]
[null,null,null,"•",null,"I confirm that I have no other equipment that meets this need."]
[null,null,null,"•",null,"I confirm that I will care for this equipment as per the instructions received from my Therapist and/or an authorized supplier. "]
[]
[null,null,null,"•",null,"I confirm that I will have all repairs, maintenance and other related equipment completed/provided by an authorized supplier who is currently under contract with Social Development."]
[]
[null,null,null,"•",null,"I confirm that I will operate this equipment safely. "]
[null,null,null,"•",null,"I confirm that I will not abuse or misuse the equipment"]
[null,null,null,"•",null,"I understand that this agreement will terminate when this equipment is replaced or no longer required. "]
[]
[]
["Client signature",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Witness"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"OR"]
[]
[]
["Legal guardian's signature *",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Date"]
[]
["* 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. "]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["SOCIAL DEVELOPMENT\nHealth Services Program\nP.O. Box 5500, Fredericton, N.B., E3B 5G4\nToll Free Number: 1-844-551-3015\nFax: (506) 453-3960",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DÉVELOPPEMENT SOCIAL\nProgramme des services de santé\nC.P. 5500, Fredericton N.-B., E3B 5G4\nNuméro sans frais: 1-844-551-3015\nTélécopieur: (506) 453-3960"]
[]
[]
[]
["Client Name: ",null,null,null,null,null,null,{"$f":"Cover!H16","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card ID: ",null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H18","v":0}]
["Part II - To be completed by an Occupational Therapist or Physiotherapist:"]
[]
[null,"1.",null,"Please complete this section for the equipment and/or component(s) that was not provided by the Health Services program and that the client would like to have maintained. "]
[]
[]
[null,"2.",null,"All options and components related to the equipment that the client wants to have maintained MUST be disclosed on this application, even if they do not require attention at the time of the application. If these options or related components have Health Services eligibility criteria, the criteria met must be provided on the Application. **"]
[]
[]
["• Please refer to the MAELP Guide for eligible benefits and related criteria."]
[]
["REQUEST #1"]
["Type of equipment:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Category:"]
["Benefit: ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Make, model and size:"]
["Reason for request:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Does the client meet ALL eligibility criteria? \n\n(Refer to MAELP guide)"]
[]
[]
[]
[]
["Location of installation",null,null,null,null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Permanent installation by the supplier?"]
["(Transfer aids only)"]
["Options / Additional Services\n\n(Where applicable only, \nsee MAELP guide.)",null,null,null,null,null,null,null,null,null,null,null,"Category",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Benefit",null,null,null,null,null,null,null,null,null,null,null,null,"ALL eligibility criteria met? (See MAELP guide)"]
[]
[]
[]
[]
["Additional information / Specifications:",null,null,null,null,null,null,null,null,null,null,null," "]
[]
["*","Part D required"]
[]
["REQUEST #2"]
["Type of equipment:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Category:"]
["Benefit: ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Make, model and size:"]
["Reason for request:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Does the client meet ALL eligibility criteria? \n\n(Refer to MAELP guide)"]
[]
[]
[]
[]
["Location of installation",null,null,null,null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Permanent installation by the supplier?"]
["(Transfer aids only)"]
["Options / Additional Services\n\n(Where applicable only, \nsee MAELP guide.)",null,null,null,null,null,null,null,null,null,null,null,"Category",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Benefit",null,null,null,null,null,null,null,null,null,null,null,null,"ALL eligibility criteria met? (See MAELP guide)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Please select..."]
[]
[]
[]
["Additional information / Specifications:",null,null,null,null,null,null,null,null,null,null,null," "]
[]
["*","Part D required"]
[]
[]
["REQUEST #3"]
["Type of equipment:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Category:",null,null,null,null,null,null,null,null,null,null,null,"Please select..."]
["Benefit: ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Make, model and size:"]
["Reason for request:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Does the client meet ALL eligibility criteria? \n\n(Refer to MAELP guide)"]
[]
[]
[]
[]
["Location of installation",null,null,null,null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Permanent installation by the supplier?"]
["(Transfer aids only)"]
["Options / Additional Services\n\n(Where applicable only, \nsee MAELP guide.)",null,null,null,null,null,null,null,null,null,null,null,"Category",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Benefit",null,null,null,null,null,null,null,null,null,null,null,null,"ALL eligibility criteria met? (See MAELP guide)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Please select..."]
[]
[]
[]
["Additional information / Specifications:"]
[]
["*","Part D required"]
[]
["THERAPIST'S SIGNATURE"]
[]
[null,null,null,"I confirm that the equipment listed above meets this client's current medical needs and that this equipment is either currently in good repair or only in need of minor repairs. "]
[]
[]
[]
[]
[null,null,null,"Therapist's name",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Date"]

{"sheet":"A-4","index":4,"n_rows":37,"n_cols":58,"rows_kept":37,"cut":false,"hidden":true,"merged":[[0,57,0,81],[1,57,1,81],[0,0,3,21],[5,0,5,55],[0,53,1,56],[0,36,3,52],[4,0,4,6],[4,7,4,26],[4,28,4,38],[4,39,4,55],[6,0,6,55],[8,43,8,55],[8,32,8,42],[8,20,8,31],[8,0,8,19],[9,0,10,19],[9,20,10,31],[9,32,10,42],[9,43,10,55],[11,0,12,19],[11,20,12,31],[11,32,12,42],[11,43,12,55],[24,0,24,55],[13,32,14,42],[13,43,14,55],[15,0,16,19],[15,20,16,31],[15,32,16,42],[15,43,16,55],[13,0,14,19],[13,20,14,31],[26,3,29,54],[33,3,35,27],[33,31,35,54],[17,32,18,42],[17,43,18,55],[19,0,20,19],[19,20,20,31],[19,32,20,42],[19,43,20,55],[17,0,18,19],[17,20,18,31],[30,3,32,54],[21,0,22,19],[21,20,22,31],[21,32,22,42],[21,43,22,55]]}
["SOCIAL DEVELOPMENT\nHealth Services Program\nP.O. Box 5500, Fredericton, N.B., E3B 5G4\nToll Free Number: 1-844-551-3015\nFax: (506) 453-3960",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DÉVELOPPEMENT SOCIAL\nProgramme des services de santé\nC.P. 5500, Fredericton N.-B., E3B 5G4\nNuméro sans frais: 1-844-551-3015\nTélécopieur: (506) 453-3960",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H16","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H18","v":0}]
[]
[]
["Client Name: ",null,null,null,null,null,null,{"$f":"Cover!H16","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card ID: ",null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H18","v":0}]
["MOBILITY AND ADAPTIVE EQUIPMENT LOAN PROGRAM"]
["PART A-4 PURCHASE OF TRIAL EQUIPMENT"]
[]
["Equipment (make / model)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Serial number",null,null,null,null,null,null,null,null,null,null,null,"Date manufactured",null,null,null,null,null,null,null,null,null,null,"New or Demo equipment"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["THERAPIST'S SIGNATURE"]
[]
[null,null,null,"I confirm that I have read and I understand the policies and procedures related to the purchase of trial equipment as outlined in the Trial Equipment Purchase Policy and Procedures."]
[]
[]
[]
[null,null,null,"I have determined that the trial equipment requested above meets this client's needs exactly as it is and I am requesting it be purchased for this client. "]
[]
[]
[]
[]
[]
[null,null,null,"Therapist's name",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Date"]

{"sheet":"B-C","index":5,"n_rows":45,"n_cols":58,"rows_kept":45,"cut":false,"hidden":false,"merged":[[0,57,0,81],[1,57,1,81],[0,0,3,21],[5,0,5,55],[0,53,1,56],[0,36,3,52],[4,0,4,6],[4,7,4,26],[4,28,4,38],[4,39,4,55],[41,0,41,11],[44,1,45,55],[7,0,10,55],[11,0,13,55],[23,0,23,55],[25,0,25,55],[29,3,30,55]]}
["SOCIAL DEVELOPMENT\nHealth Services Program\nP.O. Box 5500, Fredericton, N.B., E3B 5G4\nToll Free Number: 1-844-551-3015\nFax: (506) 453-3960",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DÉVELOPPEMENT SOCIAL\nProgramme des services de santé\nC.P. 5500, Fredericton N.-B., E3B 5G4\nNuméro sans frais: 1-844-551-3015\nTélécopieur: (506) 453-3960",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H16","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H18","v":0}]
[]
[]
["Client Name: ",null,null,null,null,null,null,{"$f":"Cover!H16","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card ID: ",null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H18","v":0}]
["PART B - CONSENT TO RELEASE INFORMATION"]
[]
["I consent to the sharing of my/ my ________________________________________ (state relationship) personal health information among the following parties, including but not limited to Social Development, Easter Seals NB, my occupational therapist(s) or physiotherapist(s) and the chosen authorized service provider. "]
[]
[]
[]
["This authorisation allows all parties to communicate by telephone, fax, email, memo and text for the purpose of obtaining the equipment prescribed. "]
[]
[]
[]
[]
["Client signature",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Witness"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"OR"]
[]
[]
["Legal guardian's signature *",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Date"]
[]
[]
["PART C - EQUIPMENT LOAN AGREEMENT"]
[]
["I understand and agree with the following terms and conditions: "]
[]
[null,"•",null,"The equipment will be loaned to me for as long as it is required."]
[null,"•",null,"The equipment must be cared for as instructed by my therapist and/or service provider."]
[null,"•",null,"Repairs and maintenance will be provided at no cost by the Health Services Program, as long as my Health Card remains active with the correct coverage and I have upheld the terms of this agreement. "]
[]
[]
[null,"•",null,"This equipment must be operated safely at all times. "]
[null,"•",null,"This equipment must not be abused or misused"]
[]
[]
[]
["Client signature",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Witness"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"OR"]
[]
[]
["Legal guardian's signature",null,null,null,null,null,null,null,null,null,null,null,"1",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Date"]
[]
[]
["1.","If someone other than the client has signed this form, then they are agreeing on the client's behalf to accept responsibility for upholding the terms of the equipment loan. "]

{"sheet":"D","index":6,"n_rows":13,"n_cols":58,"rows_kept":13,"cut":false,"hidden":false,"merged":[[12,0,13,55],[15,0,53,81],[9,0,11,55],[4,0,4,6],[4,7,4,26],[4,28,4,38],[4,39,4,55],[0,57,0,81],[1,57,1,81],[0,0,3,21],[5,0,5,55],[7,0,7,55],[0,52,1,56],[0,36,3,51]]}
["SOCIAL DEVELOPMENT\nHealth Services Program\nP.O. Box 5500, Fredericton, N.B., E3B 5G4\nToll Free Number: 1-844-551-3015\nFax: (506) 453-3960",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DÉVELOPPEMENT SOCIAL\nProgramme des services de santé\nC.P. 5500, Fredericton N.-B., E3B 5G4\nNuméro sans frais: 1-844-551-3015\nTélécopieur: (506) 453-3960",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H16","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H18","v":0}]
[]
[]
["Client Name: ",null,null,null,null,null,null,{"$f":"Cover!H16","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card ID: ",null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H18","v":0}]
["PART D - ADDITIONAL INFORMATION"]
[]
["Please use this space to provide justification for ALL exceptions"]
[]
["Please refer to the section \"How To Complete Part D the Equipment Request Form\" in the Mobility and Adaptive Equipment Loan Program guide for the specific guidance on what information is required."]
[]
[]
["Note: When completing Part D, please remember to use “alt-enter” to move from the end of one line to the beginning of the next"]

{"sheet":"BADD","index":7,"n_rows":27,"n_cols":15,"rows_kept":27,"cut":false,"hidden":true,"merged":[]}
["List1TypeEquip",null,"AmbulationAids",null,"Bathroom Aids",null,"TransferAids",null,"OtherBasicAdaptiveAids",null,"ListBA4",null,"BATAaids",null,"NoOptions"]
["Ambulation Aids",null,"Basic Ambulation Aid",null,"Bathing Aids",null,"Patient Supports",null,"Bed positioning device",null,"Basic Ambulation Aid Options",null,"Additional Services",null,"No options"]
["Bathroom Aids",null,"Basic Walker",null,"Toileting Aids",null,"Basic Transfer Aid",null,"Other positioning devices"]
["Transfer Aids",null,"4-wheeled Walker",null,null,null,null,null,"Personal Safety devices"]
["Other adaptive equipment"]
[]
[null,null,"BasicAmbulationAid",null,"BathingAids",null,"PatientSupports",null,"Bed positioning device",null,"ListBA5",null,"BATABen",null,"NoOptions2"]
[null,null,"Cane",null,"Basic shower/bath chair",null,"Bed assist rail",null,"Foam wedge",null,"Basket",null,"Modifications",null,"No options"]
[null,null,"Crutches",null,"Bath board",null,"Installed grab bar",null,"Off-loading heel protectors",null,"Cane holder"]
[null,null,"Forearm crutches",null,"Hand held shower",null,"Installed pole style stability aid",null,null,null,"Forearm supports"]
[null,null,"Hemi walker",null,"Tub transfer bench",null,"Tub side grab bar",null,"Otherpositioningdevices",null,"Ice grips/ picks"]
[null,null,null,null,null,null,null,null,"Full hand resting splint",null,"Oxygen tank holder"]
[null,null,null,null,null,null,null,null,"Palm protector",null,"Sliders/ skis"]
[null,null,"BasicWalkers",null,null,null,null,null,null,null,"Slow down brakes"]
[null,null,"Standard walker",null,"ToiletingAids",null,null,null,"PersonalSafetydevices",null,"Tray"]
[null,null,"2-wheeled walker",null,"Basic commode",null,null,null,"Protective head gear"]
[null,null,null,null,"Raised toilet seat",null,"AdditionalServices2"]
[null,null,null,null,"Reducer ring",null,"Modifications"]
[null,null,null,null,"Toilet base riser"]
[null,null,"4-wheeledWalker",null,"Toilet Safety frame",null,"BasTransAid"]
[null,null,"4-wheeled walker",null,null,null,"Transfer belt"]
[null,null,null,null,null,null,"Transfer board"]
[null,null,null,null,null,null,"Transfer disc"]
[null,null,null,null,null,null,"Transfer sheet"]
[null,null,"BasicAmbAidOptions"]
[null,null,null,null,"AdditionalServices1"]
[null,null,null,null,"Modifications"]

{"sheet":"BALU","index":8,"n_rows":25,"n_cols":3,"rows_kept":25,"cut":false,"hidden":true,"merged":[]}
["Category 1"]
["Ambulation Aids","AmbulationAids","ListBA4"]
["Bathroom Aids","Bathroom_Aids","BATAaids"]
["Transfer Aids","TransferAids","BATAaids"]
["Other adaptive equipment","OtherBasicAdaptiveAids","NoOptions"]
[]
["Basic Ambulation Aid","BasicAmbulationAid","BasicAmbulationAid"]
["Basic Walker","BasicWalkers","BasicWalkers"]
["4-wheeled Walker","_4_wheeledWalker","_4_wheeledWalker"]
["Basic Ambulation Aid Options","ListBA5","ListBA5"]
["Bathing Aids","BathingAids","BathingAids"]
["Toileting Aids","ToiletingAids","ToiletingAids"]
["Additional Services","BATABen","BATABen"]
["Patient Supports","PatientSupports","PatientSupports"]
["Basic Transfer Aid","BasTransAid","BasTransAid"]
["Bed positioning device","Bed_positioning_device","Bed_positioning_device"]
["Other positioning devices","Otherpositioningdevices","Otherpositioningdevices"]
["Personal Safety devices","PersonalSafetyDevices","PersonalSafetyDevices"]
["No options",null,"NoOptions2"]
[]
["New request"]
["Change in client’s weight "," "]
["Change in client’s medical status"]
["Current equipment not medically appropriate"]
["Current equipment not repairable *"]

{"sheet":"CoverDD","index":9,"n_rows":13,"n_cols":1,"rows_kept":13,"cut":false,"hidden":true,"merged":[]}
["Request Status"]
["New"]
["Resubmission"]
[]
["Risk"]
["Client currently at severe risk to self or others"]
["Client is at risk of deterioration"]
["Client is at risk of deterioration and a risk to self/others"]
["Application"]
["Part A-1 – Application for Equipment Loan"]
["Part A-2 – Application for Cost Sharing"]
["Part A-3 – Application for Equipment Maintenance"]
["Part A-4 – Application for Purchase of Trial Equipment"]