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["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,null,{"$f":"Cover!$H$16","v":0}]
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[]
[]
[]
["MOBILITY AND ADAPTIVE EQUIPMENT LOAN PROGRAM"]
["COMPLEX ADAPTIVE AIDS EQUIPMENT REQUEST FORM"]
[]
["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:"]
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["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"]
[null,null,null,null,null,null,null,null,null,null,"Part A-5 – Application for Equipment Transfer"]
[null,null,null,null,null,null,null,null,null,null,"Part A-6 – Application for Equipment for Multiple Users"]
[]
["ADDITIONAL DOCUMENTS INCLUDED"]
[]
[null,null,null,"Part D",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Estimate"]
[null,null,null,"Manufacturer's order 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,"Quote on Health Services E-form"]
[null,null,null,"Proof of MSRP",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Landlord permission to install letter"]
[null,null,null,"Private insurance predetermination letter",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Lift installation diagram including room dimensions"]
[null,null,null,"Other",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"proposed tracking and permanent fixtures"]

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[]
[]
[]
["Client name:",null,null,null,null,null,null,{"$f":"Cover!$H$16","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card #:",null,null,null,null,null,null,null,{"$f":"Cover!$H$18","v":0}]
[]
["MOBILITY AND ADAPTIVE EQUIPMENT LOAN PROGRAM"]
["PART A-1  APPLICATION FOR EQUIPMENT LOAN"]
[]
["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,"Size / Dimension:"]
["Eligibility criteria numbers met **",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Preferred make & model:"]
[]
["Options / Additional Services"]
["Category",null,null,null,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,null,null,null,null,null,null,null,"Eligibility criteria #'s met **"]
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[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Non-negotiable options (for recycled equipment):"]
[]
[]
["Additional information / Specifications"]
[]
[]
["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,"Size / Dimension:"]
["Eligibility criteria numbers met **",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Preferred make & model:"]
[]
["Options / Additional Services"]
["Category",null,null,null,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,null,null,null,null,null,null,null,"Eligibility criteria #'s met **"]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Non-negotiable options (for recycled equipment):"]
[]
[]
["Additional information / Specifications"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["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,"Size / Dimension:"]
["Eligibility criteria numbers met **",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Preferred make & model:"]
[]
["Options / Additional Services"]
["Category",null,null,null,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,null,null,null,null,null,null,null,"Eligibility criteria #'s met **"]
[]
[]
[]
[]
[]
[]
[]
[]
["Non-negotiable options (for recycled equipment):"]
[]
[]
["Additional information / Specifications"]
[]
[]
["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,"Size / Dimension:"]
["Eligibility criteria numbers met **",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Preferred make & model:"]
[]
["Options / Additional Services"]
["Category",null,null,null,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,null,null,null,null,null,null,null,"Eligibility criteria #'s met **"]
[]
[]
[]
[]
[]
[]
[]
[]
["Non-negotiable options (for recycled equipment):"]
[]
[]
["Additional information / Specifications"]
[]
[]
["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,"Size / Dimension:"]
["Eligibility criteria numbers met **",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Preferred make & model:"]
[]
["Options / Additional Services"]
["Category",null,null,null,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,null,null,null,null,null,null,null,"Eligibility criteria #'s met **"]
[]
[]
[]
[]
[]
[]
[]
[]
["Non-negotiable options (for recycled equipment):"]
[]
[]
["Additional information / Specifications"]
[]
[]
["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,"Size / Dimension:"]
["Eligibility criteria numbers met **",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Preferred make & model:"]
[]
["Options / Additional Services"]
["Category",null,null,null,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,null,null,null,null,null,null,null,"Eligibility criteria #'s met **"]
[]
[]
[]
[]
[]
[]
[]
[]
["Non-negotiable options (for recycled equipment):"]
[]
[]
["Additional information / Specifications"]
[]
[]
["Request #7"]
["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,"Size / Dimension:"]
["Eligibility criteria numbers met **",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Preferred make & model:"]
[]
["Options / Additional Services"]
["Category",null,null,null,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,null,null,null,null,null,null,null,"Eligibility criteria #'s met **"]
[]
[]
[]
[]
[]
[]
[]
[]
["Non-negotiable options (for recycled equipment):"]
[]
[]
["Additional information / Specifications"]
[]
[]
[]
[]
["** PLEASE COMPLETE PART D IF ALL ELIGIBILITY CRITERIA HAS NOT BEEN MET"]
["EQUIPMENT NO LONGER IN USE"]
["Equipment",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ESNB Inventory #",null,null,null,null,null,null,null,null,null,null,"Returning to ESNB?",null,null,null,null,null,null,"If no, please indicate reason:"]
[]
[]
[]
[]
[]
[]
[]
[]
["SHIPPING INSTRUCTIONS"]
[]
[]
[]
[]
["THERAPIST'S SIGNATURE"]
[]
[null,null,null,null,"I understand that if a trial in 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,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,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,"Date"]

{"sheet":"A-2","index":2,"n_rows":173,"n_cols":59,"rows_kept":173,"cut":false,"hidden":true,"merged":[[16,22,16,28],[170,4,171,27],[170,31,171,54],[163,0,163,55],[165,1,165,2],[165,4,167,54],[168,1,168,2],[168,4,169,54],[160,0,161,20],[160,21,161,31],[160,32,161,38],[160,39,161,55],[156,0,157,20],[156,21,157,31],[156,32,157,38],[156,39,157,55],[158,0,159,20],[158,21,159,31],[158,32,159,38],[158,39,159,55],[150,47,150,55],[152,0,152,55],[153,0,153,55],[154,0,155,20],[154,21,155,31],[154,32,155,38],[154,39,155,55],[147,42,147,55],[148,0,149,14],[148,15,149,55],[145,42,145,55],[146,42,146,55],[145,0,145,21],[146,0,146,21],[147,0,147,21],[145,22,145,41],[146,22,146,41],[147,22,147,41],[143,42,143,55],[144,42,144,55],[141,42,141,55],[142,42,142,55],[141,0,141,21],[142,0,142,21],[143,0,143,21],[144,0,144,21],[141,22,141,41],[142,22,142,41],[143,22,143,41],[144,22,144,41],[138,0,138,55],[139,0,139,21],[139,22,139,41],[139,42,139,55],[140,42,140,55],[135,0,135,5],[135,6,135,23],[135,25,135,36],[135,37,135,55],[136,0,137,10],[136,11,137,55],[140,0,140,21],[140,22,140,41],[132,47,132,55],[134,0,134,9],[134,10,134,23],[134,25,134,36],[134,37,134,55],[129,42,129,55],[130,0,131,14],[130,15,131,55],[129,0,129,21],[129,22,129,41],[127,42,127,55],[128,42,128,55],[125,42,125,55],[126,42,126,55],[125,0,125,21],[126,0,126,21],[127,0,127,21],[128,0,128,21],[125,22,125,41],[126,22,126,41],[127,22,127,41],[128,22,128,41],[123,42,123,55],[124,42,124,55],[120,0,120,55],[121,0,121,21],[121,22,121,41],[121,42,121,55],[122,42,122,55],[122,0,122,21],[123,0,123,21],[124,0,124,21],[122,22,122,41],[123,22,123,41],[124,22,124,41],[116,0,116,9],[116,10,116,23],[116,25,116,36],[116,37,116,55],[117,0,117,5],[117,6,117,23],[117,25,117,36],[117,37,117,55],[118,0,119,10],[118,11,119,55],[100,47,100,55],[97,42,97,55],[98,0,99,14],[98,15,99,55],[95,42,95,55],[96,42,96,55],[95,0,95,21],[96,0,96,21],[97,0,97,21],[95,22,95,41],[96,22,96,41],[97,22,97,41],[93,42,93,55],[94,42,94,55],[91,42,91,55],[92,42,92,55],[91,0,91,21],[92,0,92,21],[93,0,93,21],[94,0,94,21],[91,22,91,41],[92,22,92,41],[93,22,93,41],[94,22,94,41],[88,0,88,55],[89,0,89,21],[89,22,89,41],[89,42,89,55],[90,42,90,55],[85,0,85,5],[85,6,85,23],[85,25,85,36],[85,37,85,55],[86,0,87,10],[86,11,87,55],[90,0,90,21],[90,22,90,41],[80,0,81,14],[80,15,81,55],[82,47,82,55],[84,0,84,9],[84,10,84,23],[84,25,84,36],[84,37,84,55],[79,42,79,55],[79,0,79,21],[79,22,79,41],[77,42,77,55],[78,42,78,55],[75,42,75,55],[76,42,76,55],[75,0,75,21],[76,0,76,21],[77,0,77,21],[78,0,78,21],[75,22,75,41],[76,22,76,41],[77,22,77,41],[78,22,78,41],[74,42,74,55],[71,0,71,21],[71,22,71,41],[71,42,71,55],[72,42,72,55],[73,42,73,55],[72,0,72,21],[73,0,73,21],[74,0,74,21],[72,22,72,41],[73,22,73,41],[74,22,74,41],[22,0,23,11],[22,12,23,30],[24,12,25,30],[24,0,25,11],[24,31,25,40],[24,41,25,55],[22,41,23,55],[22,31,23,40],[57,0,60,21],[57,36,60,51],[62,7,62,27],[62,28,62,35],[62,36,62,55],[27,0,31,55],[32,0,33,55],[44,0,45,23],[44,28,45,51],[49,0,50,23],[49,28,50,51],[68,0,69,10],[70,0,70,55],[66,0,66,9],[0,52,0,55],[0,0,3,21],[0,36,3,51],[5,0,5,6],[5,7,5,27],[5,28,5,35],[5,36,5,55],[68,11,69,55],[7,0,7,55],[8,0,8,55],[10,1,11,54],[13,1,14,54],[18,0,20,55],[66,10,66,23],[66,25,66,36],[66,37,66,55],[67,0,67,5],[67,6,67,23],[67,25,67,36],[67,37,67,55],[62,0,62,6]]}
["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,null,{"$f":"Cover!$H$16","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!$H$18","v":0}]
[]
[]
[]
["Client name:",null,null,null,null,null,null,{"$f":"Cover!$H$16","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card #:",null,null,null,null,null,null,null,{"$f":"Cover!$H$18","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."]
[]
[]
["•","Any requests for FSCD 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,"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,"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,"•","I agree to care for this equipment as instructed"]
[null,"•","I will have all repairs and maintenance completed by a supplier that is currently under contract with Social Development"]
[null,"•","I agree to operate this equipment safely"]
[null,"•","I agree to not abuse or misuse this equipment"]
[null,"•","I agree to return this equipment to ESNB once it is no longer required"]
[]
["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,"OR"]
[]
[]
[]
["Legal guardian 1",null,null,null,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"]
[]
[]
["1.","If someone other than the client signs this agreement, they are agreeing on the client's behalf to uphold all terms and "]
[null,"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!$H$16","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card #:",null,null,null,null,null,null,null,{"$f":"Cover!$H$18","v":0}]
[]
["Part II - to be completed by an Occupational Therapist or Physiotherapist"]
[]
["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"]
["Eligibility criteria numbers met **"]
[]
["Options / Additional Services"]
["Category",null,null,null,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,null,null,null,null,null,null,null,"Eligibility criteria #'s met **"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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"]
[]
[]
["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"]
["Eligibility criteria numbers met **"]
[]
["Options / Additional Services"]
["Category",null,null,null,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,null,null,null,null,null,null,null,"Eligibility criteria #'s met **"]
[]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["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"]
["Eligibility criteria numbers met **"]
[]
["Options / Additional Services"]
["Category",null,null,null,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,null,null,null,null,null,null,null,"Eligibility criteria #'s met **"]
[]
[]
[]
[]
[]
[]
[]
[]
["Additional information / Specifications"]
[]
[]
["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"]
["Eligibility criteria numbers met **"]
[]
["Options / Additional Services"]
["Category",null,null,null,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,null,null,null,null,null,null,null,"Eligibility criteria #'s met **"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Please select..."]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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"]
[]
[]
[]
["** PLEASE COMPLETE PART D IF ALL ELIGIBILITY CRITERIA HAS NOT BEEN MET"]
["EQUIPMENT NO LONGER IN USE"]
["Equipment",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ESNB Inventory #",null,null,null,null,null,null,null,null,null,null,"Returning to ESNB?",null,null,null,null,null,null,"If no, please indicate reason:"]
[]
[]
[]
[]
[]
[]
[]
[]
["THERAPIST'S SIGNATURE"]
[]
[null,null,null,null,"I understand that if a trial in 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,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,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,"Date"]

{"sheet":"A-3","index":3,"n_rows":177,"n_cols":59,"rows_kept":177,"cut":false,"hidden":true,"merged":[[148,0,149,10],[148,11,149,24],[148,25,149,36],[148,37,149,55],[127,0,128,10],[127,11,128,24],[127,25,128,36],[127,37,128,55],[102,0,103,10],[102,11,103,24],[102,25,103,36],[102,37,103,55],[107,42,107,55],[108,42,108,55],[104,0,104,55],[105,0,105,21],[105,22,105,41],[105,42,105,55],[106,42,106,55],[106,0,106,21],[107,0,107,21],[108,0,108,21],[106,22,106,41],[107,22,107,41],[15,0,17,55],[18,0,22,55],[0,0,3,21],[0,36,3,51],[5,0,5,6],[5,7,5,27],[5,28,5,35],[5,36,5,55],[7,0,7,55],[8,0,8,55],[10,0,11,55],[0,52,0,55],[13,20,13,26],[64,0,64,6],[64,7,64,27],[64,28,64,35],[64,36,64,55],[77,0,77,9],[77,10,77,23],[77,25,77,36],[77,37,77,55],[34,0,35,23],[34,28,35,51],[39,0,40,23],[39,28,40,51],[59,0,62,21],[59,36,62,51],[83,0,83,55],[84,0,84,21],[84,22,84,41],[84,42,84,55],[85,42,85,55],[78,0,78,5],[78,6,78,23],[78,25,78,36],[78,37,78,55],[79,0,80,10],[79,11,80,24],[79,25,80,36],[79,37,80,55],[85,0,85,21],[85,22,85,41],[81,0,82,10],[81,11,82,24],[81,25,82,36],[81,37,82,55],[88,42,88,55],[89,42,89,55],[86,42,86,55],[87,42,87,55],[86,0,86,21],[87,0,87,21],[88,0,88,21],[89,0,89,21],[86,22,86,41],[87,22,87,41],[88,22,88,41],[89,22,89,41],[92,42,92,55],[93,0,94,14],[93,15,94,55],[90,42,90,55],[91,42,91,55],[90,0,90,21],[91,0,91,21],[92,0,92,21],[90,22,90,41],[91,22,91,41],[92,22,92,41],[99,0,99,5],[99,6,99,23],[99,25,99,36],[99,37,99,55],[100,0,101,10],[100,11,101,24],[100,25,101,36],[100,37,101,55],[95,47,95,55],[98,0,98,9],[98,10,98,23],[98,25,98,36],[98,37,98,55],[108,22,108,41],[111,42,111,55],[112,42,112,55],[109,42,109,55],[110,42,110,55],[109,0,109,21],[110,0,110,21],[111,0,111,21],[112,0,112,21],[109,22,109,41],[110,22,110,41],[111,22,111,41],[112,22,112,41],[116,47,116,55],[123,0,123,9],[123,10,123,23],[123,25,123,36],[123,37,123,55],[113,42,113,55],[114,0,115,14],[114,15,115,55],[113,0,113,21],[113,22,113,41],[129,0,129,55],[130,0,130,21],[130,22,130,41],[130,42,130,55],[131,42,131,55],[124,0,124,5],[124,6,124,23],[124,25,124,36],[124,37,124,55],[125,0,126,10],[125,11,126,24],[125,25,126,36],[125,37,126,55],[131,0,131,21],[131,22,131,41],[134,42,134,55],[135,42,135,55],[132,42,132,55],[133,42,133,55],[132,0,132,21],[133,0,133,21],[134,0,134,21],[135,0,135,21],[132,22,132,41],[133,22,133,41],[134,22,134,41],[135,22,135,41],[138,42,138,55],[139,0,140,14],[139,15,140,55],[136,42,136,55],[137,42,137,55],[136,0,136,21],[137,0,137,21],[138,0,138,21],[136,22,136,41],[137,22,137,41],[138,22,138,41],[145,0,145,5],[145,6,145,23],[145,25,145,36],[145,37,145,55],[146,0,147,10],[146,11,147,24],[146,25,147,36],[146,37,147,55],[141,47,141,55],[144,0,144,9],[144,10,144,23],[144,25,144,36],[144,37,144,55],[153,42,153,55],[154,42,154,55],[150,0,150,55],[151,0,151,21],[151,22,151,41],[151,42,151,55],[152,42,152,55],[152,0,152,21],[153,0,153,21],[154,0,154,21],[152,22,152,41],[153,22,153,41],[154,22,154,41],[157,42,157,55],[158,42,158,55],[155,42,155,55],[156,42,156,55],[155,0,155,21],[156,0,156,21],[157,0,157,21],[158,0,158,21],[155,22,155,41],[156,22,156,41],[157,22,157,41],[158,22,158,41],[174,3,175,25],[174,30,175,52],[162,47,162,55],[166,0,166,55],[168,1,168,2],[168,3,169,54],[171,1,171,2],[171,3,172,54],[159,42,159,55],[160,0,161,14],[160,15,161,55],[159,0,159,21],[159,22,159,41]]}
["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,null,{"$f":"Cover!$H$16","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!$H$18","v":0}]
[]
[]
[]
["Client name:",null,null,null,null,null,null,{"$f":"Cover!$H$16","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card #:",null,null,null,null,null,null,null,{"$f":"Cover!$H$18","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 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 the 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 provision 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,"1.",null,"I confirm that I own this equipment."]
[null,null,"2.",null,"I confirm that I have no other equipment to meet this need."]
[null,null,"3.",null,"I confirm that I will care for this equipment as per the instructions received from my Therapist and/or an authorized"]
[null,null,null,null,"supplier."]
[null,null,"4.",null,"I confirm that I will have all repair, maintenance and other related equipment completed/provided by an authorized "]
[null,null,null,null,"supplier one who is currently under contract with Social Development."]
[null,null,"5.",null,"I confirm that I will operate this equipment safely."]
[null,null,"6.",null,"I confirm that I will not abuse or misuse the equipment"]
[null,null,"7.",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,"OR"]
[]
[]
[]
["Legal guardian 1",null,null,null,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"]
[]
[]
["1.","If someone other than the client signs this agreement, they are agreeing on the client's behalf to uphold all terms and "]
[null,"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!$H$16","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card #:",null,null,null,null,null,null,null,{"$f":"Cover!$H$18","v":0}]
[]
["Part II - to be completed by an Occupational Therapist or Physiotherapist"]
[]
["1.",null,"Please complete this section for the equipment and/or component(s) that was not provided by the Health Services"]
[null,null,"program and that the client would like to have maintained."]
[]
["2.",null,"All options and components related to the equipment that the client wants to have maintained MUST be disclosed on this"]
[null,null,"application, even if they do not require attention at the time of the application. If these options or related components have"]
[null,null,"Health Services eligibility criteria, the criteria met must be provided on the application."]
[]
["•",null,"Please refer to the MAELP Guide for eligible benefits and related criteria."]
[]
["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"]
["Serial number:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Eligibility criteria #'s met **:"]
[]
["Age 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,"Name of the equipment purchaser:"]
[]
["Options / Additional Services"]
["Category",null,null,null,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,null,null,null,null,null,null,null,"Eligibility criteria #'s met **"]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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"]
[]
[]
[]
["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"]
["Serial number:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Eligibility criteria #'s met **:"]
[]
["Age 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,"Name of the equipment purchaser:"]
[]
["Options / Additional Services"]
["Category",null,null,null,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,null,null,null,null,null,null,null,"Eligibility criteria #'s met **"]
[]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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"]
[]
[]
[]
[]
[]
[]
[]
["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"]
["Serial number:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Eligibility criteria #'s met **:"]
[]
["Age 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,"Name of the equipment purchaser:"]
[]
["Options / Additional Services"]
["Category",null,null,null,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,null,null,null,null,null,null,null,"Eligibility criteria #'s met **"]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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"]
[]
[]
[]
["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,"Select after category...",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Make & model"]
["Serial number:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Eligibility criteria #'s met **:"]
[]
["Age 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,"Name of the equipment purchaser:"]
[]
["Options / Additional Services"]
["Category",null,null,null,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,null,null,null,null,null,null,null,"Eligibility criteria #'s met **"]
[]
[]
[]
[]
[]
[]
[]
[]
["Additional information / Specifications"]
[]
[]
[]
["Please complete Part D if ALL criteria are not met."]
[]
["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,"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,"Date"]

{"sheet":"A-4","index":4,"n_rows":42,"n_cols":59,"rows_kept":42,"cut":false,"hidden":true,"merged":[[0,0,3,21],[0,36,3,51],[5,0,5,6],[5,7,5,27],[5,28,5,35],[5,36,5,55],[0,52,0,55],[7,0,7,55],[8,0,8,55],[10,47,11,55],[10,0,11,26],[10,27,11,36],[10,37,11,46],[12,47,13,55],[12,37,13,46],[12,27,13,36],[12,0,13,26],[14,0,15,26],[14,27,15,36],[14,37,15,46],[14,47,15,55],[16,0,17,26],[16,27,17,36],[16,37,17,46],[16,47,17,55],[18,0,19,26],[18,27,19,36],[18,37,19,46],[18,47,19,55],[20,0,21,26],[20,27,21,36],[20,37,21,46],[20,47,21,55],[22,0,23,26],[22,27,23,36],[22,37,23,46],[22,47,23,55],[35,1,35,2],[35,3,37,54],[39,1,40,23],[39,28,40,50],[26,0,26,55],[28,1,28,2],[28,3,30,54],[32,1,32,2],[32,3,33,54]]}
["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,null,{"$f":"Cover!$H$16","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!$H$18","v":0}]
[]
[]
[]
["Client name:",null,null,null,null,null,null,{"$f":"Cover!$H$16","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card #:",null,null,null,null,null,null,null,{"$f":"Cover!$H$18","v":0}]
[]
["MOBILITY AND ADAPTIVE EQUIPMENT LOAN PROGRAM"]
["PART A-4  APPLICATION TO PURCHASE TRIAL EQUIPMENT"]
[]
["Equipment (Make / Model)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Serial #",null,null,null,null,null,null,null,null,null,"Date manufactured",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 understand that purchase of trial equipment will ONLY be considered once Health Services confrims that ESNB does not have the required equipment available. "]
[]
[]
[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 that it be purchased for the Mobility and Adaptive Equipment Loan Program and then loaned to this client."]
[]
[]
[]
[]
[]
[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,"Date"]

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["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,null,{"$f":"Cover!$H$16","v":0}]
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[]
[]
[]
["Client name:",null,null,null,null,null,null,{"$f":"Cover!$H$16","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card #:",null,null,null,null,null,null,null,{"$f":"Cover!$H$18","v":0}]
[]
["MOBILITY AND ADAPTIVE EQUIPMENT LOAN PROGRAM"]
["PART A-5  APPLICATION FOR EQUIPMENT TRANSFER"]
[]
["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"]
["Serial number",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Eligibility criteria met (#'s) **"]
[]
["Initials of previous user:",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 # of previous user:"]
[]
["ESNB inventory #",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Has equipment been cleaned & disinfected?"]
[]
["Options** / Additional Services"]
["Category",null,null,null,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,null,null,null,null,null,null,null,"Eligibility criteria #'s met **"]
[]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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"]
[]
[]
["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"]
["Serial number",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Eligibility criteria met (#'s) **"]
[]
["Initials of previous user:",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 # of previous user:"]
[]
["ESNB inventory #",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Has equipment been cleaned & disinfected?"]
[]
["Options** / Additional Services"]
["Category",null,null,null,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,null,null,null,null,null,null,null,"Eligibility criteria #'s met **"]
["ADL Positioning Additional Services",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"]
[]
[]
[]
[]
[]
[]
[]
[]
["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"]
["Serial number",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Eligibility criteria met (#'s) **"]
[]
["Initials of previous user:",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 # of previous user:"]
[]
["ESNB inventory #",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Has equipment been cleaned & disinfected?"]
[]
["Options** / Additional Services"]
["Category",null,null,null,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,null,null,null,null,null,null,null,"Eligibility criteria #'s met **"]
[]
[]
[]
[]
[]
[]
[]
[]
["Additional information / Specifications"]
[]
[]
[]
["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:",null,null,null,null,null,null,null,null,null,null,null,"Please select..."]
["Benefit:",null,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,"Make & Model"]
["Serial number",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Eligibility criteria met (#'s) **"]
[]
["Initials of previous user:",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 # of previous user:"]
[]
["ESNB inventory #",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Has equipment been cleaned & disinfected?"]
[]
["Options** / Additional Services"]
["Category",null,null,null,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,null,null,null,null,null,null,null,"Eligibility criteria #'s met **"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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"]
[]
[]
[]
["** PLEASE COMPLETE PART D IF ALL ELIGIBILITY CRITERIA HAS NOT BEEN MET"]
[]
["THERAPIST'S SIGNATURE"]
[]
[null,null,null,"I confirm that the equipment requested for transfer has been trialed with the client and that it meets their current medical needs."]
[]
[]
[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,"Date"]

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["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,null,{"$f":"Cover!$H$16","v":0}]
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[]
[]
[]
["Client name:",null,null,null,null,null,null,{"$f":"Cover!$H$16","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card #:",null,null,null,null,null,null,null,{"$f":"Cover!$H$18","v":0}]
[]
["MOBILITY AND ADAPTIVE EQUIPMENT LOAN PROGRAM"]
["PART A-6  APPLICATION FOR EQUIPMENT FOR MULTIPLE USERS"]
[]
["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,"Size / Dimension:"]
["Eligibility criteria numbers met **",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Preferred make & model:"]
[]
["The client named on the cover sheet of this request is:"]
["Options / Additional Services"]
["Category",null,null,null,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,null,null,null,null,null,null,null,"Eligibility criteria #'s met **"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Non-negotiable options (for recycled equipment):"]
[]
[]
["Additional information / Specifications"]
[]
[]
[]
["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,null,"Select after category...",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Size / Dimension:"]
["Eligibility criteria numbers met **",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Preferred make & model:"]
[]
["The client named on the cover sheet of this request is:"]
["Options / Additional Services"]
["Category",null,null,null,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,null,null,null,null,null,null,null,"Eligibility criteria #'s met **"]
[]
[]
[]
[]
[]
[]
[]
[]
["Non-negotiable options (for recycled equipment):"]
[]
[]
["Additional information / Specifications"]
[]
[]
[]
[]
[]
[]
[]
["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,"Size / Dimension:"]
["Eligibility criteria numbers met **",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Preferred make & model:"]
[]
["The client named on the cover sheet of this request is:"]
["Options / Additional Services"]
["Category",null,null,null,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,null,null,null,null,null,null,null,"Eligibility criteria #'s met **"]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[" ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Non-negotiable options (for recycled equipment):"]
[]
[]
["Additional information / Specifications"]
[]
[]
[]
["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,"Size / Dimension:"]
["Eligibility criteria numbers met **",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Preferred make & model:"]
[]
["The client named on the cover sheet of this request is:"]
["Options / Additional Services"]
["Category",null,null,null,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,null,null,null,null,null,null,null,"Eligibility criteria #'s met **"]
[]
[]
[]
[]
[]
[]
[]
[]
["Non-negotiable options (for recycled equipment):"]
[]
[]
["Additional information / Specifications"]
[]
[]
[]
["** PLEASE COMPLETE PART D IF ALL ELIGIBILITY CRITERIA HAS NOT BEEN MET"]
[]
["THERAPIST'S SIGNATURE"]
[]
[null,null,null,"I understand that if a trial is not completed and the equipment 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,"Date"]

{"sheet":"B-C","index":7,"n_rows":49,"n_cols":59,"rows_kept":49,"cut":false,"hidden":false,"merged":[[0,0,3,21],[0,36,3,51],[7,0,7,55],[9,0,12,55],[13,0,15,55],[5,0,5,6],[5,7,5,27],[5,28,5,35],[5,36,5,55],[0,52,0,55],[16,0,16,23],[16,28,16,51],[20,0,20,23],[20,28,20,51],[24,0,24,55],[43,1,43,12],[46,0,47,55],[48,0,49,55],[28,3,29,55],[31,3,32,55],[37,1,38,24],[37,29,38,52],[42,1,42,24],[42,29,42,52]]}
["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,null,{"$f":"Cover!$H$16","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!$H$18","v":0}]
[]
[]
[]
["Client name:",null,null,null,null,null,null,{"$f":"Cover!$H$16","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card #:",null,null,null,null,null,null,null,{"$f":"Cover!$H$18","v":0}]
[]
["PART B - CONSENT TO RELEASE OF 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 supplier. "]
[]
[]
[]
["This autorization 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,"OR"]
[]
[]
["Legal guardian 2",null,null,null,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,"1.",null,"The equipment will be loaned to me for as long as it is required. Once it is replaced or no longer required, I will contact Easter Seals NB at 1-888-280-8155 to determine if it must be returned to the program. 1"]
[]
[null,"2.",null,"The equipment must be cared for as instructed by my therapist and/or service provider."]
[null,"3.",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 tems of this agreement."]
[]
[null,"4.",null,"Repairs and maintenance must be completed by an authorized service provider."]
[null,"5.",null,"This equipment must be operated safely at all times."]
[null,"6.",null,"This equipment must not be abused or misused."]
[]
[]
[]
[null,"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,"OR"]
[]
[]
[null,"Legal guardian 2",null,null,null,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"]
[]
[]
["1. Any cost associated with the return of the equipment to ESNB will be taken care of by the Health Services Program."]
[]
["2. 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."]

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["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,null,{"$f":"Cover!$H$16","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!$H$18","v":0}]
[]
[]
[]
["Client name:",null,null,null,null,null,null,{"$f":"Cover!$H$16","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card #:",null,null,null,null,null,null,null,{"$f":"Cover!$H$18","v":0}]
[]
["PART D - ADDITIONAL INFORMATION"]
[]
["Please use this space to provide the following required information:"]
[]
["•",null,"Please refer to the section \"How To Complete Part D of the Equipment Request Form\" in the Mobility and Adaptive Equipment Loan Program Guide for 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":"VL123","index":9,"n_rows":20,"n_cols":2,"rows_kept":20,"cut":false,"hidden":true,"merged":[]}
["123DD"]
["Complex Ambulation Aids","ComplexAmbulationAids"]
["Complex Bathroom Aids","ComplexBathroomAids"]
["Complex Stability Aids","ComplexStabilityAids"]
["Complex Transfer Aids","ComplexTransferAids"]
["Therapeutic Sleep Aids","TherapeuticSleepAids"]
["ADL Positioning","ADLPositioning"]
[]
["123VList"]
["Ambulation aids","AmbulationAids"]
["Bathing aids","BathingAids"]
["Toileting aids","ToiletingAids"]
["Standing aids","StandingAids"]
["Transfer aids","TransferAids"]
["Patient lifts","PatientLifts"]
["Hospital beds","HospitalSleepBeds"]
["Reactive support surface","ReactiveSupport"]
["Active support surface","ActiveSupport"]
["Pressure redistributing cushions","PressureRedistributing"]
["Positioning for ADL performance","PositioningforADL"]

{"sheet":"Sheet1","index":10,"n_rows":18,"n_cols":2,"rows_kept":18,"cut":false,"hidden":true,"merged":[]}
["Complex Ambulation Aids","ComplexAbulationAidsB"]
["Complex Bathroom Aids","ComplexBathroomAidsB"]
["Complex Stability Aids","ComplexStabilityAidsB"]
["Complex Transfer Aids","ComplexTransferAidsB"]
["Therapeutic Sleep Aids","TherapeuticSleepAidsB"]
["ADL Positioning","ADLPositioningB"]
[]
["Complex Ambulation Aids Options","ComplexAmbulationAidsOptions"]
["Complex Ambulation Aids Additional Services","ComplexAmbulationAidsAdditionalServices"]
["Complex Bathroom Aids Options","ComplexBathroomAidsOptions"]
["Complex Bathroom Aids Additional Services","ComplexBathroomAidsAdditionalServices"]
["Stability Aids Options","StabilityAidsOptions"]
["Stability Aids Additional Services","StabilityAidsAdditionalServices"]
["Transfer Aids Options","TransferAidsOptions"]
["Transfer Aid Additional Services","TransferAidsAdditionalServices"]
["Therapeutic Sleep Aid Options","TherapeuticSleepAidsOptions"]
["Therapeutic Sleep Aid Additional Services","TherapeuticSleepAidsAdditionalServices"]
["ADL Positioning Additional Services","ADLPos"]

{"sheet":"L123","index":11,"n_rows":20,"n_cols":14,"rows_kept":20,"cut":false,"hidden":true,"merged":[]}
["List1A",null,null,"ComplexAmbulationAids",null,"ComplexBathroomAids",null,"ComplexStabilityAids",null,"ComplexTransferAids",null,"TherapeuticSleepAids",null,"ADLPositioning"]
["Complex Ambulation Aids","ComplexAmbulationAids",null,"Ambulation aids",null,"Bathing aids",null,"Standing aids",null,"Transfer aids",null,"Hospital beds",null,"Pressure redistributing cushions"]
["Complex Bathroom Aids","ComplexBathroomAids",null,null,null,"Toileting aids",null,null,null,"Patient lifts",null,"Reactive support surface",null,"Positioning for ADL performance"]
["Complex Stability Aids","ComplexStabilityAids",null,null,null,null,null,null,null,null,null,"Active support surface"]
["Complex Transfer Aids","ComplexTransferAids"]
["Therapeutic Sleep Aids","TherapeuticSleepAids",null,"AmbulationAids",null,"BathingAids",null,"StandingAids",null,"TransferAids",null,"HospitalSleepBeds",null,"PressureRedistributing"]
["ADL Positioning","ADLPositioning",null,"Gait trainer",null,"Complex bath chair",null,"Standing frame",null,"Free standing over-bed trapeze bar",null,"Standard hospital bed",null,"Surface for toileting or bathing"]
[null,null,null,"Specialized walker",null,"Bath lift",null,null,null,"Non-powered standing transfer aid",null,"Bariatric hospital bed",null,"Cushion outside a wheelchair"]
["Ambulation aids","AmbulationAids",null,"Platform walker",null,null,null,null,null,null,null,"Non-standard size hospital bed"]
["Bathing aids","BathingAids",null,null,null,"ToiletingAids",null,null,null,"PatientLifts",null,"Specialized bed",null,"PositioningforADL"]
["Toileting aids","ToiletingAids",null,null,null,"Toilet seat mounted bidet",null,null,null,"Power/hydraulic patient lift",null,"Specialized enclosed bed",null,"Specialty chairs & inserts"]
["Standing aids","StandingAids",null,null,null,"Complex toilet mounted support",null,null,null,"Portable overhead lift"]
["Transfer aids","TransferAids",null,null,null,"Complex commode",null,null,null,"Ceiling track tracking",null,"ReactiveSupport"]
["Patient lifts","PatientLifts",null,null,null,"Complex shower chair",null,null,null,"Slings",null,"High density foam mattress"]
["Hospital beds","HospitalSleepBeds",null,null,null,"Shower commode with tilt",null,null,null,null,null,"Mattress overlay system"]
["Reactive support surface","ReactiveSupport",null,null,null,null,null,null,null,null,null,"Non-powered support surface"]
["Active support surface","ActiveSupport"]
["Pressure redistributing cushions","PressureRedistributing",null,null,null,null,null,null,null,null,null,"ActiveSupport"]
["Positioning for ADL performance","PositioningforADL",null,null,null,null,null,null,null,null,null,"Powered active support suface"]
[null,null,null,null,null,null,null,null,null,null,null,"Multizone surface"]

{"sheet":"L145","index":12,"n_rows":20,"n_cols":14,"rows_kept":20,"cut":false,"hidden":true,"merged":[]}
["CAList1-B",null,null,"ComplexAbulationAidsB",null,"ComplexBathroomAidsB",null,"ComplexStabilityAidsB",null,"ComplexTransferAidsB",null,"TherapeuticSleepAidsB",null,"ADLPositioningB"]
["Complex Ambulation Aids","ComplexAbulationAidsB",null,"Complex Ambulation Aids Options",null,"Complex Bathroom Aids Options",null,"Stability Aids Options",null,"Transfer Aids Options",null,"Therapeutic Sleep Aid Options",null,"ADL Positioning Additional Services"]
["Complex Bathroom Aids","ComplexBathroomAidsB",null,"Complex Ambulation Aids Additional Services",null,"Complex Bathroom Aids Additional Services",null,"Stability Aids Additional Services",null,"Transfer Aid Additional Services",null,"Therapeutic Sleep Aid Additional Services"]
["Complex Stability Aids","ComplexStabilityAidsB"]
["Complex Transfer Aids","ComplexTransferAidsB"]
["Therapeutic Sleep Aids","TherapeuticSleepAidsB"]
["ADL Positioning","ADLPositioningB",null,"ComplexAmbulationAidsOptions",null,"ComplexBathroomAidsOptions",null,"StabilityAidsOptions",null,"TransferAidsOptions",null,"TherapeuticSleepAidsOptions",null,"ADLPos"]
[null,null,null,"Attendant guide bar",null,"Mobility frame",null,"Head support",null,"Additional tracking",null,"Additional bed rail(s)",null,"Modifications"]
["Complex Ambulation Aids Options","ComplexAmbulationAidsOptions",null,"Head support",null,"Pressure reduction surface",null,"Lower extremity positioning",null,"Track longer than 3 meters",null,"Bed rail padding/covers",null,"Rentals"]
["Complex Ambulation Aids Additional Services","ComplexAmbulationAidsAdditionalServices",null,"Lower extremety support",null,"Additional positioning options",null,"Trunk support",null,"portable extension straps",null,"Bed width/length extension"]
["Complex Bathroom Aids Options","ComplexBathroomAidsOptions",null,"Non-standard base",null,null,null,"Upper extremity support",null,null,null,"Bolster"]
["Complex Bathroom Aids Additional Services","ComplexBathroomAidsAdditionalServices",null,"Non-standard upper frame",null,"ComplexBathroomAidsAdditionalServices",null,null,null,"TransferAidsAdditionalServices",null,"Large mattress cover"]
["Stability Aids Options","StabilityAidsOptions",null,"Non-standard wheels",null,"Modifications",null,"StabilityAidsAdditionalServices",null,"Modifications",null,"Modular therapeutic sections"]
["Stability Aids Additional Services","StabilityAidsAdditionalServices",null,"Seat/Sling seat",null,"Rentals",null,"Modifications",null,"Rentals",null,"Positioning mattress overlay"]
["Transfer Aids Options","TransferAidsOptions",null,"Trunk support",null,null,null,"Rentals",null,null,null,"Second mattress cover"]
["Transfer Aid Additional Services","TransferAidsAdditionalServices",null,"Upper extremity support",null,null,null,null,null,null,null,"Trendelenburg feature"]
["Therapeutic Sleep Aid Options","TherapeuticSleepAidsOptions"]
["Therapeutic Sleep Aid Additional Services","TherapeuticSleepAidsAdditionalServices",null,"ComplexAmbulationAidsAdditionalServices",null,null,null,null,null,null,null,"TherapeuticSleepAidsAdditionalServices"]
["ADL Positioning Additional Services","ADLPos",null,"Modifications",null,null,null,null,null,null,null,"Modifications"]
[null,null,null,"Rental",null,null,null,null,null,null,null,"Rentals"]