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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\n",null,null,null,null,null,null,null,null,null,null,null,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\n",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"K16","v":0}]
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[]
[]
[]
["MOBILITY AND ADAPTIVE EQUIPMENT LOAN PROGRAM"]
["BASIC ADAPTIVE AIDS EQUIPMENT TRIAL REQUEST FORM (BA-TERF)"]
[]
["Send completed trial equipment request form to: "]
[]
["Supplier/Agency:"]
[]
["Supplier Sales Rep:"]
[]
["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,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"]
["Phone number:"]
["Complete address:"]
["Health card ID#",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Expiry 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,null,null,null,null,null,null,null,null,null,null,null,null,null,"DD",null,null,null,"MM",null,null,null,null,null,"YYYY"]
[]
["THERAPIST INFORMATION"]
["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,null,null,null,null,"Agency/Office"]
["Telephone:",null,null,null,null,null,null,null,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:"]
["E-mail:"]
["Alternative contact name:"]
["Preferred method of Communication:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"E-mail",null,null,null,null,null,null,null,null,null,"Phone",null,null,null,null,null,null,null,null,null,null,"Either"]
[]
["BASIC ADAPTIVE AIDS – EQUIPMENT REQUEST DETAILS"]
["DATE",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"URGENT"]
[null,null,null,null,null,"DD",null,null,null,"MM",null,null,null,null,null,"YYYY"]
[null,null,"Trial equipment",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Quote",null,null,null,null,null,null,null,null,null,"Amended Request      "]
["Substitutions acceptable for items requested below?",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Request for Cost sharing?"]
[null,null,"Yes (Call to discuss with therapist)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"No",null,null,null,null,null,null,null,null,null,"Yes",null,null,null,null,null,null,null,null,null,null,null,null,null,"No"]
["Basic Adaptive Aids"]
["Type of Equipment",null,null,null,null,null,null,null,null,null,null,null,null,"Specifications: (Make/Model/Size/Options)"]
[]
[]
[]
[]
[]
[]
["THERAPIST'S SIGNATURE"]
[]
[null,"By signing and dating this request, I understand that the trial period with the supplier’s equipment is for a maximum of 14 days and that it is my responsibility to notify the Supplier immediately following the trial period to indicate if the trial was successful or not. I also understand that only the most cost effective equipment to meet my client’s current basic needs within the parameters of the MAELP will be considered for approval, even as an exception."]
[]
[]
[]
[null,null,null,"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,"Date"]

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["FIRSTONE",null,"TypeFoot",null,"FootrestTERF"]
["National Seating and Mobility, Moncton    -- 467 Adelard Savoie BLVD, Dieppe NB, E1A 7E7 ",null,"Adjustable Angle Composite",null,60]
["National Seating and Mobility, Fredericton  -- 1142 Smythe St., Fredericton NB, E3B 3H5 ",null,"Adjustable Composite  Aluminum",null,70]
["Harding Medical Supplies -- 175 Caledonia Rd Unit #2, Moncton NB, E1H 2S5",null,"NONE",null,80]
["Lawtons Home Health Care, Moncton -- 800 Mountain Rd, Moncton, NB, E1C 2R4",null,null,null,90]
["Lawtons Home Health Care, Saint John -- 107 Catherwood Street, Saint John NB, E2M 5J7",null,null,null,"Elevating"]
["Restair -- 127 Brunswick St, Dalhousie NB, E8C 1G7",null,null,null,"Foot platform"]
["Tango Medical, Fredericton -- 100 Woodside Lane B103, Fredericton NB, E3C 2R9",null,null,null,"NONE"]
["Tango Medical, Moncton -- 355 Elmwood Drive, Moncton NB, E1A 1X6"]
["Tango Medical, Saint John -- 358 Rothesay Avenue Suite 701, Saint John NB, E2J 2C4"]
[]
[]
[]
[]
[null,null,"HS Staff"]
["RecAgent",null,"BA – ALL Client ID #’s:  Angela Mullins -- angela.mullins@gnb.ca --  Fax to Email: 506-444-4629"]
["National Seating and Mobility, Moncton (506) 854-2548 -- moncton@nsm-seating.com"]
["National Seating and Mobility, Fredericton (506) 854-2548 -- fredericton@nsm-seating.com"]
["Harding Medical, Moncton (506) 855-5113 -- doreen.sullivan@HardingMedical.com"]
["Lawtons Home Health Care, Moncton (506) 855-1838 -- Carolyne.Parent@sobeys.com"]
["Lawtons Home Health Care, Saint John (506) 657-9742 -- Anne.Spencer@sobeys.com"]
["Restair Ltd (506) 684-5345 --  info@restair.ca"]
["Tango Medical, Fredericton  (506) 452-7449, c.bradshaw@tangomedical.ca"]
["Tango Medical, Moncton  (506) 855-8843, a.robichaud@tangomedical.ca"]
["Tango Medical, Saint John   (506) 634-7404, w.richard@tangomedical.ca"]

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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\n",null,null,null,null,null,null,null,null,null,null,null,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\n",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"H22","v":0}]
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["MOBILITY AND ADAPTIVE EQUIPMENT LOAN PROGRAM",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"AL34","v":0}]
["BASIC ADAPTIVE AIDS EQUIPMENT REQUEST FORM (BA ERF)"]
[]
["Send completed equipment request form to: "]
[]
["Program Administrator:"]
[]
[]
["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:"]
["Prescriber #"]
["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,"Health Card Exp 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,"Medical diagnosis:"]
["Is the client awaiting placement?",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"If yes, is the scheduled placement date within 30 days?"]
["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"]
[]
["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,"Quote on a Health Services Claim Form"]
[null,null,null,"Landlord 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",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Proof of MSRP"]
[]
["ADDITIONAL INFORMATION – DELIVERY / INSTALLATION"]
[]
[null,null,null,"Supplier to deliver equipment to the client or the therapist’s office."]
[null,null,null,"Supplier to install equipment."]
[null,null,null,"Therapist / Landlord to install the equipment."]
[null,null,null,"Other: "]

{"sheet":"A-1","index":3,"n_rows":142,"n_cols":58,"rows_kept":142,"cut":false,"hidden":true,"merged":[[136,1,138,54],[112,0,112,45],[131,0,131,45],[129,0,130,11],[129,12,130,55],[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],[126,12,126,30],[126,31,126,43],[128,12,128,30],[128,31,128,43],[115,37,115,55],[134,0,134,55],[128,44,128,55],[104,0,104,11],[97,0,97,4],[97,5,97,24],[97,25,97,36],[97,37,97,55],[98,0,102,11],[103,0,103,11],[103,12,104,33],[112,46,112,55],[109,12,109,30],[106,44,106,55],[107,44,107,55],[108,44,108,55],[109,44,109,55],[110,0,111,11],[110,12,111,55],[105,0,109,11],[105,12,105,30],[105,31,105,43],[105,44,105,55],[106,31,106,43],[107,31,107,43],[108,31,108,43],[109,31,109,43],[107,12,107,30],[108,12,108,30],[114,45,114,54],[115,0,115,11],[115,12,115,24],[115,25,115,36],[127,12,127,30],[116,0,116,4],[116,5,116,24],[116,25,116,36],[116,37,116,55],[117,0,121,11],[127,31,127,43],[125,44,125,55],[126,44,126,55],[127,44,127,55],[87,31,87,43],[88,31,88,43],[89,31,89,43],[95,45,95,54],[93,0,93,45],[93,46,93,55],[86,12,86,30],[87,12,87,30],[88,12,88,30],[106,12,106,30],[103,34,104,50],[103,51,104,55],[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],[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],[70,0,72,11],[70,12,72,55],[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],[67,31,67,43],[68,31,68,43],[69,31,69,43],[73,46,73,55],[66,44,66,55],[67,44,67,55],[68,44,68,55],[69,44,69,55],[67,12,67,30],[68,12,68,30],[69,12,69,30],[73,0,73,45],[66,12,66,30],[10,12,14,55],[15,12,16,33],[55,0,55,11],[46,46,46,55],[42,44,42,55],[46,0,46,45],[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],[56,0,56,11],[56,12,56,24],[56,25,56,36],[56,37,56,55],[43,0,45,11],[43,12,45,55],[20,44,20,55],[31,12,35,55],[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],[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],[40,31,40,43],[41,31,41,43],[39,12,39,30],[40,12,40,30],[41,12,41,30],[42,12,42,30],[39,44,39,55],[40,44,40,55],[41,44,41,55],[42,31,42,43],[139,3,140,27],[139,31,140,54],[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],[29,37,29,55],[25,46,25,55],[28,0,28,11],[36,0,36,11],[98,12,102,55],[117,12,121,55],[86,44,86,55],[87,44,87,55],[88,44,88,55],[89,44,89,55],[29,12,29,24],[29,25,29,36],[36,34,37,50],[89,12,89,30],[15,34,16,50],[15,51,16,55],[10,0,14,11],[15,0,15,11],[16,0,16,11],[58,12,62,55],[78,12,82,55],[21,44,21,55],[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],[18,12,18,30],[19,12,19,30],[20,12,20,30],[21,12,21,30],[18,44,18,55],[19,44,19,55],[36,12,37,33],[29,0,29,11]]}
["SOCIAL DEVELOPMENT\nHealth Services Program\nP.O. Box 5500, Fredericton, N.B., E3B 5G4\nToll Free Number: 1-844-551-3015",null,null,null,null,null,null,null,null,null,null,null,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\n",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H22","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H24","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!K30","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!AL32","v":0}]
["Client Name: ",null,null,null,null,null,null,{"$f":"Cover!H22","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card ID: ",null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H24","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!AL33","v":0}]
["MOBILITY AND ADAPTIVE EQUIPMENT LOAN PROGRAM",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!AL34","v":0}]
["PART A-1 APPLICATION FOR EQUIPMENT LOAN"]
["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 and Model"]
["ALL eligibility criteria numbers met ** (A,B,C)"]
[]
[]
[]
[]
["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?"]
["(Patient supports 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 #’s met**(A,B,C)"]
[]
[]
[]
[]
["Additional information / Specifications:"]
[]
[]
["IF all eligibility criteria have not been met, you may request consideration of an exception by completing Part D."]
[]
[]
["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 and Model"]
["ALL eligibility criteria numbers met ** (A,B,C)"]
[]
[]
[]
[]
["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?"]
["(Patient supports 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 #’s met**(A,B,C)"]
[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:"]
[]
[]
["IF all eligibility criteria have not been met, you may request consideration of an exception by completing Part D."]
[]
[]
[]
[]
[]
[]
[]
[]
["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,"Select after category...",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Make and Model"]
["ALL eligibility criteria numbers met ** (A,B,C)"]
[]
[]
[]
[]
["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?"]
["(Patient supports 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 #’s met**(A,B,C)"]
[]
[]
[]
[]
["Additional information / Specifications:"]
[]
[]
["IF all eligibility criteria have not been met, you may request consideration of an exception by completing Part D."]
[]
["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 and Model"]
["ALL eligibility criteria numbers met ** (A,B,C)"]
[]
[]
[]
[]
["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?"]
["(Patient supports 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 #’s met**(A,B,C)"]
[]
[]
[]
[]
["Additional information / Specifications:"]
[]
[]
["IF all eligibility criteria have not been met, you may request consideration of an exception by completing Part D."]
[]
["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 and Model"]
["ALL eligibility criteria numbers met ** (A,B,C)"]
[]
[]
[]
[]
["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?"]
["(Patient supports 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 #’s met**(A,B,C)"]
[]
[]
[]
[]
["Additional information / Specifications:"]
[]
["IF all eligibility criteria have not been met, you may request consideration of an exception by completing Part D."]
[]
["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 and Model"]
["ALL eligibility criteria numbers met ** (A,B,C)"]
[]
[]
[]
[]
["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?"]
["(Patient supports 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 #’s met**(A,B,C)"]
[]
[]
[]
[]
["Additional information / Specifications:"]
[]
["IF all eligibility criteria have not been met, you may request consideration of an exception by completing Part D."]
[]
[]
["THERAPIST'S SIGNATURE"]
[]
[null,"By signing and dating this request, I confirm that I have completed an assessment on the above noted client and at this time, the prescribed equipment meets the client's basic needs within the parameters of the Mobility and Adaptive Equipment Loan Program."]
[]
[]
[]
[]
[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":4,"n_rows":134,"n_cols":58,"rows_kept":134,"cut":false,"hidden":true,"merged":[[128,3,130,54],[72,44,72,55],[73,44,73,55],[74,44,74,55],[90,44,90,55],[91,44,91,55],[92,44,92,55],[93,44,93,55],[121,0,122,11],[121,12,122,55],[126,0,126,55],[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],[81,37,81,55],[82,0,86,11],[82,12,86,55],[118,31,118,43],[119,31,119,43],[118,12,118,30],[119,12,119,30],[120,12,120,30],[117,44,117,55],[118,44,118,55],[119,44,119,55],[120,44,120,55],[0,0,3,21],[5,0,5,55],[6,0,6,55],[22,34,23,44],[22,11,23,33],[22,45,23,55],[62,0,62,5],[62,6,62,24],[62,25,62,36],[62,37,62,55],[63,0,67,11],[63,12,67,55],[25,0,31,55],[22,0,23,10],[54,0,57,21],[54,36,57,56],[59,0,59,55],[61,0,61,11],[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],[20,11,21,33],[8,0,12,55],[16,0,18,55],[20,0,21,10],[20,45,21,55],[14,21,14,27],[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],[68,34,69,50],[70,0,74,11],[75,0,76,11],[75,12,76,55],[74,31,74,43],[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],[72,31,72,43],[73,31,73,43],[71,12,71,30],[72,12,72,30],[73,12,73,30],[74,12,74,30],[71,44,71,55],[132,3,132,27],[132,31,132,54],[94,0,95,11],[94,12,95,55],[89,0,93,11],[89,12,89,30],[89,31,89,43],[89,44,89,55],[90,31,90,43],[91,31,91,43],[92,31,92,43],[93,31,93,43],[120,31,120,43],[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],[106,0,106,11],[107,0,107,11],[107,12,107,24],[107,25,107,36],[77,0,77,47],[96,0,96,47],[123,0,123,47],[108,25,108,36],[114,0,114,11],[114,12,115,33],[114,34,115,50],[108,37,108,55],[109,0,113,11],[109,12,113,55],[79,0,79,11],[107,37,107,55],[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]]}
["SOCIAL DEVELOPMENT\nHealth Services Program\nP.O. Box 5500, Fredericton, N.B., E3B 5G4\nToll Free Number: 1-844-551-3015\n",null,null,null,null,null,null,null,null,null,null,null,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\n",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H22","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H24","v":""}]
[]
[]
["Client Name: ",null,null,null,null,null,null,{"$f":"Cover!H22","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card ID: ",null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H24","v":""}]
["MOBILITY AND ADAPTIVE EQUIPMENT LOAN PROGRAM"]
["PART A-2 APPLICATION FOR COST SHARING"]
[]
["• Please refer to the MAELP Cost Sharing Policy and Procedures 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:"]
[]
[]
["Options that ARE NOT a benefit and / or for which the client does not qualify can be added to the equipment that has been cost shared on. HOWEVER, the cost of these options will be deducted from the quoted cost for the piece of equipment and cost sharing will apply to the eligible portion of the equipment only. ALL available funds from the private insurance will be applied to the equipment that are benefits through the MAELP and that the client qualifies for."]
[]
[]
[]
[]
[]
[]
["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 Health Services"]
[null,"•","I agree to operate this equipment safely"]
[null,"•","I agree to not abuse or misuse this equipment in any way"]
[]
["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 2"]
[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.  A legal guardian’s signature is only required when the client is unable to sign themselves.   "]
[]
[null,"An administrator of a Long Term Care facility may also sign for a client, if neither the client nor the legal guardian are able."]
[null,"When this happens, the Therapist must include a Part D to explain why neither the client nor the client’s"]
[null,"legal guardian/next of kin is able to sign.  "]
[2,"A witness is only required when the client signs with an “X” or a Stamp.  "]
[]
["SOCIAL DEVELOPMENT\nHealth Services Program\nP.O. Box 5500, Fredericton, N.B., E3B 5G4\nToll Free Number: 1-844-551-3015",null,null,null,null,null,null,null,null,null,null,null,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"]
[]
[]
[]
["Client Name: ",null,null,null,null,null,null,{"$f":"Cover!H22","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card ID: ",null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H24","v":""}]
["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 and Model"]
["ALL eligibility criteria numbers met ** (A,B,C)"]
[]
[]
[]
[]
["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?"]
["(Patient supports 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 #’s met**(A,B,C)"]
[null,null,null,null,null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[null,null,null,null,null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[null,null,null,null,null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[null,null,null,null,null,null,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:"]
[]
["*IF all eligibility criteria have not been met, you may request consideration of an exception by completing Part D."]
[]
["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 and Model"]
["ALL eligibility criteria numbers met ** (A,B,C)"]
[]
[]
[]
[]
["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?"]
["(Patient supports 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 #’s met**(A,B,C)"]
[]
[]
[]
[]
["Additional information / Specifications:"]
[]
["*IF all eligibility criteria have not been met, you may request consideration of an exception by completing Part D."]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["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 and Model"]
["ALL eligibility criteria numbers met ** (A,B,C)"]
[]
[]
[]
[]
["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?"]
["(Patient supports 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 #’s met**(A,B,C)"]
[]
[]
[]
[]
["Additional information / Specifications:"]
[]
["*IF all eligibility criteria have not been met, you may request consideration of an exception by completing Part D."]
[]
[]
["THERAPIST'S SIGNATURE"]
[]
[null,null,null,"By signing and dating this request, I confirm that I have completed an assessment on the above noted client and at this time, the prescribed equipment meets the client's basic needs within the parameters of the Mobility and Adaptive Equipment Loan Program."]
[]
[]
[]
[]
[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":5,"n_rows":135,"n_cols":58,"rows_kept":135,"cut":false,"hidden":true,"merged":[[72,12,76,55],[91,12,95,55],[111,12,115,55],[86,0,86,47],[105,0,105,47],[125,0,125,47],[42,0,45,54],[47,0,50,54],[80,44,80,55],[81,44,81,55],[82,44,82,55],[83,44,83,55],[99,44,99,55],[100,44,100,55],[101,44,101,55],[102,44,102,55],[119,44,119,55],[123,0,124,11],[123,12,124,55],[116,0,116,11],[116,12,117,33],[116,34,117,50],[116,51,117,55],[117,0,117,11],[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],[120,31,120,43],[121,31,121,43],[122,31,122,43],[120,44,120,55],[121,44,121,55],[122,44,122,55],[120,12,120,30],[121,12,121,30],[122,12,122,30],[119,12,119,30],[110,0,110,5],[110,6,110,24],[110,25,110,36],[110,37,110,55],[111,0,115,11],[103,0,104,11],[103,12,104,55],[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],[100,31,100,43],[101,31,101,43],[102,31,102,43],[96,0,96,11],[96,12,97,33],[96,34,97,50],[96,51,97,55],[97,0,97,11],[102,12,102,30],[90,0,90,5],[90,6,90,24],[90,25,90,36],[90,37,90,55],[91,0,95,11],[89,0,89,11],[89,12,89,24],[89,25,89,36],[89,37,89,55],[71,37,71,55],[39,0,41,55],[54,0,57,21],[54,36,57,56],[59,0,59,55],[70,0,70,11],[70,12,70,24],[70,25,70,36],[70,37,70,55],[72,0,76,11],[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],[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],[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],[79,0,83,11],[80,31,80,43],[81,31,81,43],[82,31,82,43],[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]]}
["SOCIAL DEVELOPMENT\nHealth Services Program\nP.O. Box 5500, Fredericton, N.B., E3B 5G4\nToll Free Number: 1-844-551-3015\n",null,null,null,null,null,null,null,null,null,null,null,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\n",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H22","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H24","v":""}]
[]
[]
["Client Name: ",null,null,null,null,null,null,{"$f":"Cover!H22","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card ID: ",null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H24","v":""}]
["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 if the application is approved, I will remain the owner of this equipment. With the approval, I understand that repairs, maintenance and/or provision of the additional related equipment or components will only be eligible for approval as long as my Health Card remains valid with the approvpriate coveragem 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 who is currently under contract with Health Services."]
[]
[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 if I am no longer eligible"]
[null,null,null,null,null,"for the equipment as per the parameters of the program."]
[]
[]
[]
["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 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,"OR"]
[]
[]
["Legal guardian's signature 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 conditions mentioned above. A legal guardian's signatureis only required when the client is unable to sign themselves. "]
[]
[]
["An administrator of a Long Term Care facility may also sign for a client, if neither the client nor the legal guadian are able. When this happensm the Therapist must include a Part D to explain why neother the client nor the client's legal guadian / next of kin is able to sign. "]
[]
[]
[]
[]
["2. A witness  is only required when the client signs with an \"X\" or a stamp."]
[]
[]
[]
[]
[]
[]
["SOCIAL DEVELOPMENT\nHealth Services Program\nP.O. Box 5500, Fredericton, N.B., E3B 5G4\nToll Free Number: 1-844-551-3015\n",null,null,null,null,null,null,null,null,null,null,null,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\n"]
[]
[]
[]
["Client Name: ",null,null,null,null,null,null,{"$f":"Cover!H22","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card ID: ",null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H24","v":""}]
["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."]
[null,null,"If additional modifications and/or components are required for the equipment listed in this form, Part A-1 –"]
[null,null,"Application for Equipment Loan of the ERF must be completed. "]
["2.",null,"All options and components related to the equipment that the client wants to have maintained MUST be"]
[null,null,"disclosed on this application, even if they do not require attention at the time of the application. If these options or"]
[null,null,"related components have Health Services eligibility criteria, the criteria met must be provided on the application."]
[]
["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 and Model"]
["ALL eligibility criteria numbers met ** (A,B,C)"]
[]
[]
[]
[]
["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?"]
["(Patient supports 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 #’s met**(A,B,C)"]
[]
[]
[]
[]
["Additional information / Specifications:",null,null,null,null,null,null,null,null,null,null,null," "]
[]
["*IF all eligibility criteria have not been met, you may request consideration of an exception by completing Part D."]
[]
["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 and Model"]
["ALL eligibility criteria numbers met ** (A,B,C)"]
[]
[]
[]
[]
["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?"]
["(Patient supports 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 #’s met**(A,B,C)"]
[null,null,null,null,null,null,null,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," "]
[]
["*IF all eligibility criteria have not been met, you may request consideration of an exception by completing Part D."]
[]
[]
["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 and Model"]
["ALL eligibility criteria numbers met ** (A,B,C)"]
[]
[]
[]
[]
["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?"]
["(Patient supports 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 #’s met**(A,B,C)"]
[null,null,null,null,null,null,null,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:"]
[]
["*IF all eligibility criteria have not been met, you may request consideration of an exception by completing Part D."]
[]
["THERAPIST'S SIGNATURE"]
[]
[null,null,null,"By signing and dating this form, I confirm that the equipment listed above meets the 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":"B-C","index":6,"n_rows":46,"n_cols":58,"rows_kept":46,"cut":false,"hidden":false,"merged":[[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],[43,0,44,55],[45,0,45,55],[34,28,34,34],[38,0,38,11],[7,0,10,55],[21,0,21,55],[23,0,23,55],[27,3,28,55],[11,0,14,55],[16,28,16,34],[18,0,18,23],[18,28,18,51],[41,0,42,55]]}
["SOCIAL DEVELOPMENT\nHealth Services Program\nP.O. Box 5500, Fredericton, N.B., E3B 5G4\nToll Free Number: 1-844-551-3015",null,null,null,null,null,null,null,null,null,null,null,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",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H22","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H24","v":""}]
[]
[]
["Client Name: ",null,null,null,null,null,null,{"$f":"Cover!H22","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card ID: ",null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H24","v":""}]
["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, The Mobility and Adaptive Equipment Loan Program, Easter Seals NB, my occupational therapist(s) or physiotherapist(s) and the chosen authorized service supplier. I understand that I may revoke my consent at any time by submitting a request in writing to Social Development."]
[]
[]
[]
["This authorization allows all parties to communicate by telephone, fax, email, memo and text for the purpose of obtaining the equipment prescribed through any of the Mobility and Adaptive Equipment Loan Programs (Basic Adaptive, Complex Adaptive, Mobility Aids and Postural Supports).\n\nThis consent is valid for a maximum of 24 months as long as there is no change to 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,"Witness3"]
[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,"•",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,"Witness3"]
[null,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. 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.\n\nAn administrator of a Long Term Care facility may also sign for a client, if neither the client nor the legal guardian are able. When this happens, the Therapist must include a note in Part D to explain why neither the client nor the client's legal guardian/next of kin is able to sign."]
[]
["3. A witness is only required when the client signs with an “X” or a Stamp. A legal guardian's signature is only required when the client is unable to sign themsleves."]

{"sheet":"D","index":7,"n_rows":12,"n_cols":58,"rows_kept":12,"cut":false,"hidden":false,"merged":[[9,2,9,55],[10,2,10,55],[11,2,12,53],[13,0,45,55],[0,0,3,21],[5,0,5,55],[0,52,1,56],[0,36,3,51],[4,0,4,6],[4,7,4,26],[4,28,4,38],[4,39,4,55],[7,2,8,55]]}
["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,{"$f":"Cover!H22","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H24","v":""}]
[]
[]
["Client Name: ",null,null,null,null,null,null,{"$f":"Cover!H22","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card ID: ",null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!H24","v":""}]
["PART D - ADDITIONAL INFORMATION"]
[]
["•",null,"Please refer to How to Complete Part D of the Equipment Request Form section in the MAELP Guide for assistance in completing Part D."]
[]
["•",null,"Only equipment that is the most cost effective and meets the client's current basic needs and that is"]
[null,null,"within the parameters of the MAELP will be considered for approval, even as an exception."]
["•",null,"The following can be used as an aid in completing Part D:  Write a brief introduction to your client (medical, functional, environmental).  Indicate each essential criteria which are not met and why."]

{"sheet":"BADD","index":8,"n_rows":28,"n_cols":15,"rows_kept":28,"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,"Curb climbers"]
[null,null,"Hemi walker",null,"Tub transfer bench",null,"Tub side grab bar",null,"Otherpositioningdevices",null,"Forearm supports"]
[null,null,null,null,null,null,"Wall Mounted Support",null,"Full hand resting splint",null,"Ice grips/ picks"]
[null,null,null,null,null,null,null,null,"Palm protector",null,"Oxygen tank holder"]
[null,null,null,null,null,null,null,null,null,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,"Commode with wheels/drop arm/foot",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":9,"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":10,"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"]