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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,{"$f":"K16","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"K21","v":0}]
[]
[]
[]
["MOBILITY AND ADAPTIVE EQUIPMENT LOAN PROGRAM"]
["MOBILITY AIDS AND POSTURAL SUPPORTS PROGRAM TRIAL EQUIPMENT REQUEST FORM (MAPS - 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"]
[]
["SUPPLIER MOBILITY AIDS AND POSTURAL SUPPORTS - 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,null,null,null,null,"Equipment NOT available from the recycling agent."]
[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"]
["Wheelchair Specifications"]
["Manual chair",null,null,null,null,null,null,null,null,null,null,null,"Folding",null,null,null,null,null,null,null,null,null,null,null,"Rigid ",null,null,null,null,null,null,null,null,null,"Tilt",null,null,null,null,null,null,null,null,null,"Power assist"]
[null,null,null,null,null,null,null,null,null,"Model 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,"Standard",null,null,null,null,null,null,null,null,null,"Hemi"]
["Power chair",null,null,null,null,null,null,null,null,null,null,null,"FWD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"MWD",null,null,null,null,null,null,null,null,null,null,null,null,null,"RWD"]
[null,null,null,null,null,null,null,null,null,"Model name: "]
[null,null,null,null,null,null,null,null,null,null,null,null,"Power positioning:"]
[null,null,null,null,null,null,null,null,null,null,null,null,"Alternative Drive Control"]
["Chair size",null,null,null,null,null,null,null,null,"Seat width",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Seat depth"]
[null,null,null,null,null,null,null,null,null,"Seat to floor height"]
[null,null,null,null,null,null,null,null,null,null,null,null,"With cushion",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Without cushion"]
[null,null,null,null,null,null,null,null,null,"Front rigging:"]
[null,null,null,null,null,null,null,null,null,"Leg length:"]
["Cushion",null,null,null,null,null,null,null,null,"Size:"]
[null,null,null,null,null,null,null,null,null,"Make / Model: "]
[null,null,null,null,null,null,null,null,null,"2nd cover required?",null,null,null,null,null,null,null,null,null,null,null,null,"Yes",null,null,null,null,null,null,"No"]
["Back",null,null,null,null,null,null,null,null,"Width:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Height:"]
[null,null,null,null,null,null,null,null,null,"Model:"]
["Arms",null,null,null,null,null,null,null,null,"Style:"]
[null,null,null,null,null,null,null,null,null,"Height:"]
[]
["Wheels",null,null,null,null,null,null,null,null,"Casters:"]
[null,null,null,null,null,null,null,null,null,"Rear:"]
[null,null,null,null,null,null,null,null,null,"Type of tires:"]
[null,null,null,null,null,null,null,null,null,"Hand rims:"]
["Wheel locks"]
["Secondary Postural Supports / Options"]
[]
["Other / Setup and delivery information"]
[]
[]
["RECYCLING AGENT MOBILITY AIDS AND POSTURAL SUPPORTS - TRANSFERS ONLY"]
["Initials of the previous client:",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 the previous client:"]
["Equipment Make / Model",null,null,null,null,null,null,null,null,null,null,null,"Size / Dimension",null,null,null,null,null,null,null,null,null,null,"Equipment Number",null,null,null,null,null,null,null,null,null,null,"Serial Number",null,null,null,null,null,null,null,null,null,null,"Purchase date"]
[]
[]
[]
[]
["RECYCLING AGENT MOBILITY AIDS AND POSTURAL SUPPORTS - EQUIPMENT REQUEST DETAILS"]
[null,null,null,null,"URGENT REQUEST (RECYCLING AGENT ONLY)"]
["Equipment Make / Model",null,null,null,null,null,null,null,null,null,null,null,"Size / Dimension",null,null,null,null,null,null,null,null,null,null,"Equipment Number",null,null,null,null,null,null,null,null,null,null,"Serial Number",null,null,null,null,null,null,null,null,null,null,"Purchase date"]
[]
[]
[]
["FRONT RIGGING"]
["Footrest Type",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Type of footplate"]
[]
[]
["RECYCLING AGENT SHIPPING INSTRUCTIONS"]
[]
[]
["THERAPIST'S SIGNATURE"]
[]
[null,null,null,"By signing and dating this request, I understand that the trial period with the Recycling Agent’s and Supplier’s equipment is for a maximum of 14 days and that it is my responsibility to notify Health Services, ESNB and the Supplier (if applicable) 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"]

{"sheet":"TERFDD","index":1,"n_rows":26,"n_cols":5,"rows_kept":26,"cut":false,"hidden":true,"merged":[]}
["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,"Plug in style"]
["Tango Medical, Moncton -- 355 Elmwood Drive, Moncton NB, E1A 1X6",null,null,null,"NONE"]
["Tango Medical, Saint John -- 358 Rothesay Avenue Suite 701, Saint John NB, E2J 2C4"]
[]
[]
[]
[]
[null,null,"HS Staff"]
["RecAgent",null,"MAPS – Client ID#’s that begin with 0 or 6: Cari Brewer -- cari.brewer@gnb.ca -- Fax to Email 506-444-4610"]
["National Seating and Mobility, Moncton (506) 854-2548 -- moncton@nsm-seating.com",null,"MAPS – Client ID#’s that begin with 8 or 9: Michelle Ricker -- michelle.ricker@gnb.ca -- Fax to Email 506-444-4635"]
["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"]
["Recycling Agent (506) 457-2863 -- loans@easterseals.nb.ca"]
["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,{"$f":"Cover!$H$22","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!$H$24","v":0}]
[]
[]
[]
["MOBILITY AND ADAPTIVE EQUIPMENT LOAN PROGRAM"]
["MOBILITY AIDS AND POSTURAL SUPPORTS EQUIPMENT REQUEST FORM (MAPS ERF)"]
[]
["Send completed trial 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:"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DD",null,null,null,"MM",null,null,null,null,null,"YYYY"]
["Health card #:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card 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"]
["Urgent request:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"If yes, indicate reason:"]
["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"]
[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"]
[]
["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 Claim 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,"Rental quote on Health Services Claim Form"]
[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,"Other"]

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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,{"$f":"Cover!$H$22","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!$H$24","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(TypeMobAidsA1=\"\",1,0)","v":1}]
[]
[]
["Client name:",null,null,null,null,null,null,{"$f":"Cover!$H$22","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card #:",null,null,null,null,null,null,null,{"$f":"Cover!$H$24","v":0}]
[]
["MOBILITY AND ADAPTIVE EQUIPMENT LOAN PROGRAM"]
["PART A-1  APPLICATION FOR EQUIPMENT LOAN"]
["Type of Mobility Aid: ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Type of postural supports:",null,null,null,null,null,null,null,null,null,"Primary Postural Support(s)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Secondary Postural Support(s)"]
[]
["MANUAL MOBILITY AID"]
["Category:",null,null,null,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,"Select after category..."]
["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,"Preferred make & model:"]
[]
["Seat width:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Seat depth:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Seat to floor height: (without cushion)"]
[]
["Means of propulsion:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Type of hand rim: "]
[]
["Armrest style:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Arm rest height:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Wheel locks: "]
[]
["Front rigging:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Casters:",null,null,null,null,null,null,null,null,null,null,null,null,"Rear wheels:",null,null,null,null,null,null,null,null,null,null,null,null,"Type of tires:"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #’s met **(A,B,C)"]
[1]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[3,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[4,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[5,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[6,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[7,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[8,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[9,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[10,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.  "]
[]
[]
[]
[]
[]
[]
[]
[]
["POWER MOBILITY AIDS"]
["Category:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Benefit"]
["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:"]
[]
["Seat width:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Seat depth:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Seat to floor height: (without cushion)"]
[]
["Armrest style:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Arm rest height:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Front rigging:"]
[]
["Drive Style",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Type of Tires"]
[]
["Casters",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Rear wheels"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #s met ** (A,B,C)"]
[1]
[2]
[3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[4,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[5,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[6,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[7,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[8,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[9,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[10,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.  "]
[]
[]
[]
[]
[]
[]
[]
["PRIMARY POSTURAL SUPPORTS"]
["REQUEST # 1"]
["Category:",null,null,null,null,null,null,null,null,"Primary Postural Supports",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,"Select after category..."]
["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,"Preferred make & model:"]
[]
["Width:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Depth:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Height:"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #s met ** (A,B,C)"]
[1]
[2]
[3]
["Additional Information / Specifications:"]
[]
["** IF all eligibility criteria have not been met, you may request consideration of an exception by completing Part D.  "]
["REQUEST # 2"]
["Category:",null,null,null,null,null,null,null,null,"Primary Postural Supports",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,"Select after category..."]
["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,"Preferred make & model:"]
[]
["Width:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Depth:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Height:"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #s met ** (A,B,C)"]
[1]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[3,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.  "]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"SECONDARY POSTURAL SUPPORTS"]
["REQUEST # 1"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Benefit"]
["ALL Eligibility criteria #s met ** (A,B,C)"]
[]
["Size/Dimensions",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"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #s met ** (A,B,C)"]
[1]
[2]
["Additional Information / Specifications:"]
[]
[]
["REQUEST # 2"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["ALL Eligibility criteria #s met ** (A,B,C)"]
[]
["Size/Dimensions",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,"Benefit",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ALL Eligibility criteria #s met ** (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
["REQUEST # 3"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["ALL Eligibility criteria #s met ** (A,B,C)"]
[]
["Size/Dimensions",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"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #s met ** (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
["REQUEST # 4"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["ALL Eligibility criteria #s met ** (A,B,C)"]
[]
["Size/Dimensions",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"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #s met ** (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
["REQUEST # 5"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["ALL Eligibility criteria #s met ** (A,B,C)"]
[]
["Size/Dimensions",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"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #s met ** (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
["REQUEST # 6"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["ALL Eligibility criteria #s met ** (A,B,C)"]
[]
["Size/Dimensions",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"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #s met ** (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
["REQUEST # 7"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["ALL Eligibility criteria #s met ** (A,B,C)"]
[]
["Size/Dimensions",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"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #s met ** (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
["REQUEST # 8"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["ALL Eligibility criteria #s met ** (A,B,C)"]
[]
["Size/Dimensions",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"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #s met ** (A,B,C)"]
[1]
[2,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.  "]
[]
["EQUIPMENT NO LONGER IN USE"]
[]
["ESNB TRIAL EQUIPMENT"]
[]
["Therapist's Name:"]
[]
[null,null,null,null,"Equipment was available which met the needs of my client based upon SD Criteria."]
[]
[null,null,null,null,"Trial with ALL ESNB equipment was successful and ALL of the equipment will be used by my client long term.  "]
[]
["TRIAL EQUIPMENT IS BEING RETURNED TO:"]
[]
[]
["ESNB TRIAL EQUIPMENT BEING RETURNED"]
["Trial 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,"ESNB Inventory #"]
["Supplier has been contacted to pick up 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,"Date of contact:"]
[]
["Trial 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,"ESNB Inventory #"]
["Supplier has been contacted to pick up 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,"Date of contact:"]
[]
["Trial 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,"ESNB Inventory #"]
["Supplier has been contacted to pick up 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,"Date of contact:"]
[]
["ESNB EQUIPMENT NO LONGER IN USE"]
["Equipment",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,"Returning to ESNB?",null,null,null,null,null,null,null,null,null,null,"If no, please indicate reason:"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["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,"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,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\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,{"$f":"Cover!$H$22","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!$H$24","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(TypesMobAids2=\"\",1,0)","v":1}]
[]
[]
["Client name:",null,null,null,null,null,null,{"$f":"Cover!$H$22","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card #:",null,null,null,null,null,null,null,{"$f":"Cover!$H$24","v":0}]
[]
["MOBILITY AND ADAPTIVE EQUIPMENT LOAN PROGRAM"]
["PART A-2  APPLICATION FOR COST SHARING"]
["Type of Mobility Aid: ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Type of postural supports:",null,null,null,null,null,null,null,null,null,"Primary Postural Support(s)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Secondary Postural Support(s)"]
[]
["•","Please refer to the MAELP Cost Sharing Policy and Procedures 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:"]
[]
[]
["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 I have been 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\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!$H$22","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card #:",null,null,null,null,null,null,null,{"$f":"Cover!$H$24","v":0}]
[]
["Part II - To be completed by an Occupational Therapist."]
[]
["MANUAL MOBILITY AIDS"]
["Category:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Benefit:"]
["Eligibility criteria # met: **",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:"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility Criteria #’s met ** (A,B,C)"]
[1,null,"Standard options - manual"]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
["Additional Information / Specifications:"]
[]
[]
[]
["POWER MOBILITY AIDS"]
["Category:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Benefit:"]
["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,"Eligibility criteria #s met**"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility Criteria #’s met ** (A,B,C)"]
[1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Select after category..."]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
["Additional Information / Specifications:"]
[]
[]
[]
["**IF all eligibility criteria have not been met, you may request consideration of an exception by completing Part D"]
[]
[]
[]
["PRIMARY POSTURAL SUPPORTS"]
["Request #1"]
["Category:",null,null,null,null,null,null,null,null,"Primary Postural Supports",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,"Select after category..."]
["Make / Model, dimensions:",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**"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility Criteria #’s met ** (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[3,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"]
["Category:",null,null,null,null,null,null,null,null,"Primary Postural Supports",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,"Select after category..."]
["Make, model and dimensions:",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**"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility Criteria #’s met ** (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[3,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."]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"SECONDARY POSTURAL SUPPORTS"]
["REQUEST # 1"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["Preferred make & model:"]
["ALL Eligiblity Criteria numbers met ** (A,B,C):"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility Criteria #’s met ** (A,B,C)"]
[1]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
["REQUEST # 2"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["Preferred make & model:"]
["ALL Eligiblity Criteria numbers met ** (A,B,C):"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility Criteria #’s met ** (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
["REQUEST # 3"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["Preferred make & model:"]
["ALL Eligiblity Criteria numbers met ** (A,B,C):"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility Criteria #’s met ** (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
["REQUEST # 4"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["Preferred make & model:"]
["ALL Eligiblity Criteria numbers met ** (A,B,C):"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility Criteria #’s met ** (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
["REQUEST # 5"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["Preferred make & model:"]
["ALL Eligiblity Criteria numbers met ** (A,B,C):"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility Criteria #’s met ** (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
["REQUEST # 6"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Benefit:"]
["Preferred make & model:"]
["ALL Eligiblity Criteria numbers met ** (A,B,C):"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility Criteria #’s met ** (A,B,C)"]
[1]
[2]
["Additional Information / Specifications:"]
[]
[]
["REQUEST # 7"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["Preferred make & model:"]
["ALL Eligiblity Criteria numbers met ** (A,B,C):"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility Criteria #’s met ** (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
["REQUEST # 8"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["Preferred make & model:"]
["ALL Eligiblity Criteria numbers met ** (A,B,C):"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility Criteria #’s met ** (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,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."]
[]
[]
["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,"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,null,null,"Date"]

{"sheet":"A-3","index":5,"n_rows":257,"n_cols":58,"rows_kept":257,"cut":false,"hidden":true,"merged":[[175,37,175,55],[176,0,177,15],[185,0,185,55],[186,0,186,15],[186,16,186,36],[186,37,186,55],[183,37,183,55],[184,0,184,8],[187,0,187,1],[187,2,187,15],[167,9,167,24],[167,25,167,36],[187,16,187,36],[187,37,187,55],[188,0,188,1],[188,2,188,15],[162,37,162,55],[157,37,157,55],[158,0,158,8],[158,9,158,55],[157,0,157,8],[183,0,183,8],[167,37,167,55],[170,0,170,8],[170,37,170,55],[171,0,171,8],[171,9,171,55],[173,16,173,36],[173,37,173,55],[174,0,174,1],[174,2,174,15],[180,25,180,36],[180,37,180,55],[176,16,177,55],[181,0,182,8],[181,9,182,55],[170,9,170,21],[170,22,170,36],[183,9,183,21],[183,22,183,36],[197,9,197,21],[197,22,197,36],[209,9,209,21],[209,22,209,36],[174,16,174,36],[188,16,188,36],[172,0,172,55],[173,0,173,15],[179,48,179,55],[180,0,180,8],[188,37,188,55],[184,9,184,55],[189,0,190,15],[189,16,190,55],[174,37,174,55],[175,0,175,1],[175,2,175,15],[175,16,175,36],[144,22,144,36],[141,0,141,8],[141,9,141,24],[166,48,166,55],[159,0,159,55],[160,0,160,15],[160,16,160,36],[160,37,160,55],[161,0,161,1],[161,2,161,15],[161,16,161,36],[161,37,161,55],[162,0,162,1],[162,2,162,15],[162,16,162,36],[163,0,164,15],[163,16,164,55],[144,0,144,8],[144,37,144,55],[142,0,143,8],[142,9,143,55],[155,0,156,8],[155,9,156,55],[180,9,180,24],[157,9,157,21],[157,22,157,36],[147,0,147,15],[147,16,147,36],[147,37,147,55],[148,0,148,1],[148,2,148,15],[148,16,148,36],[148,37,148,55],[153,48,153,55],[154,0,154,8],[154,9,154,24],[154,25,154,36],[154,37,154,55],[149,0,149,1],[149,2,149,15],[149,16,149,36],[149,37,149,55],[150,0,151,15],[150,16,151,55],[168,0,169,8],[168,9,169,55],[167,0,167,8],[112,0,112,15],[112,16,112,36],[112,47,112,55],[117,22,117,36],[117,37,117,55],[121,0,121,1],[121,2,121,15],[121,16,121,36],[121,37,121,55],[115,12,115,36],[115,47,115,55],[122,37,122,55],[123,0,124,15],[123,16,124,55],[127,0,127,8],[146,0,146,55],[145,0,145,8],[141,25,141,36],[141,37,141,55],[140,48,140,55],[139,0,139,15],[139,16,139,36],[139,47,139,55],[122,0,122,1],[122,2,122,15],[122,16,122,36],[145,9,145,55],[133,2,133,15],[133,16,133,36],[133,37,133,55],[130,0,130,8],[130,9,130,21],[130,22,130,36],[130,37,130,55],[144,9,144,21],[104,0,104,1],[104,2,104,15],[104,16,104,36],[104,37,104,55],[136,0,137,15],[136,16,137,55],[114,0,114,8],[114,9,114,24],[114,25,114,36],[114,37,114,55],[116,0,116,8],[119,0,119,15],[119,16,119,36],[119,37,119,55],[120,0,120,1],[120,2,120,15],[120,16,120,36],[120,37,120,55],[118,0,118,55],[116,25,116,36],[116,37,116,55],[116,9,116,24],[117,0,117,8],[117,9,117,21],[115,0,115,11],[99,0,99,1],[99,2,99,15],[99,16,99,36],[99,37,99,55],[100,0,100,1],[100,2,100,15],[100,16,100,36],[100,37,100,55],[101,0,101,1],[101,2,101,15],[101,16,101,36],[101,37,101,55],[102,0,102,1],[102,2,102,15],[102,16,102,36],[102,37,102,55],[105,0,107,15],[105,16,107,55],[103,0,103,1],[103,2,103,15],[103,16,103,36],[103,37,103,55],[97,0,97,1],[97,2,97,15],[97,16,97,36],[97,37,97,55],[98,0,98,1],[98,2,98,15],[98,16,98,36],[98,37,98,55],[95,0,95,15],[95,16,95,36],[95,47,95,55],[96,0,96,15],[96,16,96,36],[96,37,96,55],[93,0,93,8],[94,0,94,8],[94,37,94,55],[94,9,94,21],[94,22,94,36],[91,0,91,8],[91,9,91,24],[91,25,91,36],[91,37,91,55],[92,0,92,11],[93,9,93,24],[93,25,93,36],[93,37,93,55],[92,12,92,36],[92,47,92,55],[82,0,84,15],[82,16,84,55],[90,0,90,55],[80,0,80,1],[80,2,80,15],[80,16,80,36],[80,37,80,55],[81,0,81,1],[81,2,81,15],[81,16,81,36],[81,37,81,55],[78,0,78,1],[78,2,78,15],[78,16,78,36],[78,37,78,55],[79,0,79,1],[79,2,79,15],[79,16,79,36],[79,37,79,55],[76,0,76,1],[76,2,76,15],[76,16,76,36],[76,37,76,55],[77,0,77,1],[77,2,77,15],[77,16,77,36],[77,37,77,55],[74,0,74,1],[74,2,74,15],[74,16,74,36],[74,37,74,55],[75,0,75,1],[75,2,75,15],[75,16,75,36],[75,37,75,55],[72,0,72,15],[72,16,72,36],[72,47,72,55],[73,0,73,15],[73,16,73,36],[73,37,73,55],[71,37,71,55],[70,0,70,8],[71,0,71,8],[69,0,69,11],[70,9,70,24],[70,25,70,36],[70,37,70,55],[71,22,71,36],[71,9,71,21],[69,12,69,36],[69,47,69,55],[51,0,54,21],[51,36,54,51],[51,52,51,55],[12,2,13,55],[15,23,15,28],[17,0,19,55],[20,0,23,55],[67,0,67,55],[68,0,68,8],[68,9,68,24],[68,25,68,36],[68,37,68,55],[56,0,56,6],[56,7,56,27],[56,28,56,35],[56,36,56,55],[9,0,10,12],[9,13,10,25],[7,0,7,55],[8,0,8,55],[0,0,3,21],[0,36,3,51],[0,52,0,55],[5,0,5,6],[5,7,5,27],[5,28,5,35],[5,36,5,55],[9,26,10,26],[9,27,10,36],[9,37,9,54],[10,37,10,54],[127,9,127,24],[127,25,127,36],[127,37,127,55],[131,0,131,55],[132,0,132,15],[135,0,135,1],[135,2,135,15],[135,16,135,36],[135,37,135,55],[134,0,134,1],[134,2,134,15],[134,16,134,36],[134,37,134,55],[129,0,129,8],[132,16,132,36],[132,37,132,55],[129,9,129,24],[129,25,129,36],[133,0,133,1],[129,37,129,55],[128,0,128,11],[128,12,128,18],[128,19,128,27],[128,28,128,55],[193,0,193,8],[193,9,193,24],[193,25,193,36],[193,37,193,55],[192,48,192,55],[200,0,200,1],[200,2,200,15],[200,16,200,36],[200,37,200,55],[198,0,198,55],[199,0,199,15],[199,16,199,36],[199,37,199,55],[194,0,1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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,{"$f":"Cover!$H$22","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!$H$24","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(TypeMobAids3=\"\",1,0)","v":1}]
[]
[]
["Client name:",null,null,null,null,null,null,{"$f":"Cover!$H$22","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card #:",null,null,null,null,null,null,null,{"$f":"Cover!$H$24","v":0}]
[]
["MOBILITY AND ADAPTIVE EQUIPMENT LOAN PROGRAM"]
["PART A-3  APPLICATION FOR EQUIPMENT MAINTENANCE"]
["Type of Mobility Aid: ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Type of postural supports:",null,null,null,null,null,null,null,null,null,"Primary Postural Support(s)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Secondary Postural Support(s)"]
[]
[null,"•","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 the form. "]
[]
[]
["I understand that if the application is approved, I will remain the owner of this equipment. 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 valid with the appropriate coverage, and I agree to the following terms and conditions."]
[]
[]
[]
[]
[null,null,"•",null,"I confirm that I own this equipment."]
[null,null,"•",null,"I confirm that I have no other equipment that meets this need."]
[null,null,"•",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,"•",null,"I confirm that I will have all repairs, maintenance and other related equipment completed/provided by an authorized "]
[null,null,null,null,"supplier who is currently under contract with Health Services."]
[null,null,"•",null,"I confirm that I will operate this equipment safely."]
[null,null,"•",null,"I confirm that I will not abuse or misuse the equipment in any way."]
[null,null,"•",null,"I understand that this agreement will terminate if the equipment is replaced or if I am no longer eligible"]
[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,"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\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!$H$22","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card #:",null,null,null,null,null,null,null,{"$f":"Cover!$H$24","v":0}]
[]
["Part II - To be completed by an Occupational Therapist."]
[]
["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 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."]
["MANUAL MOBILITY AIDS"]
["Category:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Benefit:"]
["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,"Size/Dimension"]
["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,"Serial number: "]
["Age of equipment:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Provided/purchased by:"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #’s met ** (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[3,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[4,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[5,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[6,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[7,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[8,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
[]
[null,"**IF all eligibility criteria have not been met, you may request consideration of an exception by completing Part D."]
[]
[]
[]
["POWER MOBILITY AIDS"]
["Category:",null,null,null,null,null,null,null,null,"Power wheelchair",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Benefit:"]
["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,"Size/Dimension"]
["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,"Serial number:"]
["Age of equipment:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Provided/purchased by:"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #’s met ** (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[3,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[4,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[5,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[6,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[7,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[8,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."]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PRIMARY POSTURAL SUPPORTS"]
["Request #1"]
["Category:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Benefit:"]
["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,"Size/Dimension"]
["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,"Serial number:"]
["Age of equipment:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Provided/purchased by:"]
["OPTIONS / ADDITIONAL SERVICES"]
["Category",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,null,"ALL Eligibility criteria #’s met ** (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[3,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",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Requwat #1"]
["Category:",null,null,null,null,null,null,null,null,"Primary Postural Supports",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,"Select after category..."]
["Eligibility criteria #s met: **",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Size / Dimension:"]
["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,"Serial number:"]
["Age of equipment:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Provided/purchased by:"]
["OPTIONS / ADDITIONAL SERVICES"]
["Category",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,null,"ALL Eligibility criteria #’s met ** (A,B,C)"]
[1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[3,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."]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"SECONDARY POSTURAL SUPPORTS"]
["REQUEST #1"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["ALL Eligibility criteria numbers 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,"Provided/purchased by:"]
["Make & Model:"]
["OPTIONS / ADDITIONAL SERVICES"]
["Category",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,null,"ALL Eligibility criteria #’s met ** (A,B,C)"]
[1]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
["REQUEST #2"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["ALL Eligibility criteria numbers 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,"Provided/purchased by:"]
["Make & Model:"]
["OPTIONS / ADDITIONAL SERVICES"]
["Category",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,null,"ALL Eligibility criteria #’s met ** (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
["REQUEST #3"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["ALL Eligibility criteria numbers 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,"Provided/purchased by:"]
["Make & Model:"]
["OPTIONS / ADDITIONAL SERVICES"]
["Category",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,null,"ALL Eligibility criteria #’s met ** (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
["REQUEST #4"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Head support"]
["ALL Eligibility criteria numbers 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,"Provided/purchased by:"]
["Make & Model:"]
["OPTIONS / ADDITIONAL SERVICES"]
["Category",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,null,"ALL Eligibility criteria #’s met ** (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
["REQUEST #5"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["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,"Serial #"]
["ALL Eligibility criteria numbers 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,"Provided/purchased by:"]
["OPTIONS / ADDITIONAL SERVICES"]
["Category",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,null,"ALL Eligibility criteria #’s met ** (A,B,C)"]
[1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Select after category..."]
["Additional Information / Specifications:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[]
[]
["REQUEST #6"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["ALL Eligibility criteria numbers met**"]
[]
["Age of equipment:",null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,null,null,null,null,"Provided/purchased by:"]
["Make & Model:",null,null,null,null,null,null,null,null," "]
["OPTIONS / ADDITIONAL SERVICES"]
["Category",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,null,"ALL Eligibility criteria #’s met ** (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[]
[]
["REQUEST #7"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["ALL Eligibility criteria numbers met**"]
[]
["Age of equipment:",null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,null,null,null,null,"Provided/purchased by:"]
["Make & Model:"]
["OPTIONS / ADDITIONAL SERVICES"]
["Category",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,null,"ALL Eligibility criteria #’s met ** (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[]
[]
["REQUEST #8"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["ALL Eligibility criteria numbers met**"]
[]
["Age of equipment:",null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,null,null,null,null,"Provided/purchased by:"]
["Make & Model:",null,null,null,null,null,null,null,null," "]
["OPTIONS / ADDITIONAL SERVICES"]
["Category",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,null,"ALL Eligibility criteria #’s met ** (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:",null,null,null,null,null,null,null,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 all eligibility criteria have not been met, you may request consideration of an exception by completing Part D."]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[]
["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,"I confirm that the assessment for this client is complete and that this is the final request for equipment to meet this client's mobility equipment needs. "]
[]
[]
[]
[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,null,null,"Date"]

{"sheet":"A-4","index":6,"n_rows":39,"n_cols":58,"rows_kept":39,"cut":false,"hidden":true,"merged":[[7,0,7,55],[8,0,8,55],[0,0,3,21],[0,36,3,51],[0,52,0,55],[5,0,5,6],[5,7,5,27],[5,28,5,35],[5,36,5,55],[14,0,14,16],[14,17,14,25],[14,26,14,36],[14,37,14,55],[15,0,16,16],[15,17,16,25],[15,26,16,36],[15,37,16,55],[29,17,30,25],[25,17,26,25],[27,17,28,25],[17,0,18,16],[19,0,20,16],[21,0,22,16],[23,0,24,16],[29,0,30,16],[25,0,26,16],[27,0,28,16],[25,26,26,36],[27,26,28,36],[17,17,18,25],[19,17,20,25],[21,17,22,25],[23,17,24,25],[37,1,37,29],[37,31,37,54],[32,0,32,55],[34,1,35,54],[17,37,18,55],[19,37,20,55],[21,37,22,55],[23,37,24,55],[29,37,30,55],[25,37,26,55],[27,37,28,55],[17,26,18,36],[19,26,20,36],[21,26,22,36],[23,26,24,36],[29,26,30,36]]}
["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,{"$f":"Cover!$H$22","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!$H$24","v":0}]
[]
[]
[]
["Client name:",null,null,null,null,null,null,{"$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 #:",null,null,null,null,null,null,null,{"$f":"Cover!H24","v":0}]
[]
["MOBILITY AND ADAPTIVE EQUIPMENT LOAN PROGRAM"]
["PART A-4 APPLICATION TO PURCHASE TRIAL EQUIPMENT"]
[]
[null,"·",null,"Please refer to the MAELP Trial Equipment Purchase Policy and Procedures before completing this Application."]
[null,"·",null,"In addition to this Application, the Therapist must also complete the A-1 - Application for Equipment Loan"]
[null,null,null,"section of the Equipment Request Form."]
[]
["Equipment (make/model)",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,"Date manufactured",null,null,null,null,null,null,null,null,null,null,"New or demo equipment"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["THERAPIST'S SIGNATURE"]
[]
[null,"By signing and dating this request, I confirm that I have completed an assessment on the above noted client with the trial equipment specified above and it meets the client’s basic needs exactly as it is.  "]
[]
[]
[]
[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,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\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,{"$f":"Cover!$H$22","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!$H$24","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(TypesMobAids5=\"\",1,0)","v":1}]
[]
[]
["Client name:",null,null,null,null,null,null,{"$f":"Cover!H22","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card #:",null,null,null,null,null,null,null,{"$f":"Cover!H$24","v":0}]
[]
["MOBILITY AND ADAPTIVE EQUIPMENT LOAN PROGRAM"]
["PART A-5  APPLICATION FOR EQUIPMENT TRANSFER"]
["Type of Mobility Aid: ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Type of postural supports:",null,null,null,null,null,null,null,null,null,"Primary Postural Support(s)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Secondary Postural Support(s)"]
[null,null,"Please refer to the MAELP Equipment Transfer Policy and Procedures before completing this Application.  \n\nIn addition to this Application, the Therapist must also complete the A-1 - Application for Equipment Loan section of the Equipment Request Form if they are requesting additional equipment that is not being transferred."]
["MANUAL MOBILITY AIDS"]
["Category:",null,null,null,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,"Select after category..."]
["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,"Serial #:"]
["Size / Dimension:",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 **"]
["Initials of previous client:",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 client:"]
[]
["ESNB \nEquipment # :",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 & dinsinfected?"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #’s met **   (A,B,C)"]
[1,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[3,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[4,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[5,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[6,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
[]
["POWER MOBILITY AIDS"]
["Category:",null,null,null,null,null,null,null,null,"Power wheelchair",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Benefit:"]
["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,"Serial #:"]
["Size / Dimension:",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 **"]
["Initials of previous client:",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 client:"]
[]
["ESNB \nEquipment # :",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 & dinsinfected?"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #’s met **   (A,B,C)"]
[1,null," "]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[3,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[4,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[5,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[6,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.  "]
[]
["PRIMARY POSTURAL SUPPORTS"]
["Request #1"]
["Category:",null,null,null,null,null,null,null,null,"Primary Postural Supports",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,"Select after category..."]
["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,"Serial #:"]
["Size / Dimension:",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 **"]
["Initials of Previous Client:",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 client :"]
[]
["ESNB \nEquipment #:",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 & dinsinfected?"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #s met ** (A,B,C)"]
[1]
[2]
[3,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"]
["Category:",null,null,null,null,null,null,null,null,"Primary Postural Supports",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,"Select after category..."]
["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,"Serial #:"]
["Size / Dimension:",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 **"]
["Initials of Previous Client:",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 client :"]
[]
["ESNB \nEquipment #:",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 & dinsinfected?"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #s met ** (A,B,C)"]
[1]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[3,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.  "]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"SECONDARY POSTURAL SUPPORTS"]
["REQUEST #1"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["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,"Serial #:"]
["Size / Dimension:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ALL Eligibility criteria #’s met **   (A,B,C):"]
["Initials of Previous Client:",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 client :"]
[]
["ESNB \nEquipment # :",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 & dinsinfected?"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #s met ** (A,B,C)"]
[1]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[3,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
["REQUEST #2"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["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,"Serial #:"]
["Size / Dimension:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ALL Eligibility criteria #’s met **   (A,B,C):"]
["Initials of Previous Client:",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 client :"]
[]
["ESNB \nEquipment # :",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 & dinsinfected?"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #s met ** (A,B,C)"]
[1]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[3,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
["REQUEST #3"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["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,"Serial #:"]
["Size / Dimension:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ALL Eligibility criteria #’s met **   (A,B,C):"]
["Initials of Previous Client:",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 client :"]
[]
["ESNB \nEquipment # :",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 & dinsinfected?"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #s met ** (A,B,C)"]
[1]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[3,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
["REQUEST #4"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["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,"Serial #:"]
["Size / Dimension:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ALL Eligibility criteria #’s met **   (A,B,C):"]
["Initials of Previous Client:",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 client :"]
[]
["ESNB \nEquipment # :",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 & dinsinfected?"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #s met ** (A,B,C)"]
[1]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[3,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[]
[]
["REQUEST #5"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["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,"Serial #:"]
["Size / Dimension:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ALL Eligibility criteria #’s met **   (A,B,C):"]
["Initials of Previous Client:",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 client :"]
[]
["ESNB \nEquipment # :",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 & dinsinfected?"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #s met ** (A,B,C)"]
[1]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[3,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
["REQUEST #6"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["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,"Serial #:"]
["Size / Dimension:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ALL Eligibility criteria #’s met **   (A,B,C):"]
["Initials of Previous Client:",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 client :"]
[]
["ESNB \nEquipment # :",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 & dinsinfected?"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #s met ** (A,B,C)"]
[1]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[3,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
["REQUEST #7"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["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,"Serial #:"]
["Size / Dimension:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ALL Eligibility criteria #’s met **   (A,B,C):"]
["Initials of Previous Client:",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 client :"]
[]
["ESNB \nEquipment # :",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 & dinsinfected?"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #s met ** (A,B,C)"]
[1]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[3,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
["Additional Information / Specifications:"]
[]
[]
["REQUEST #8"]
["Category:",null,null,null,null,null,null,null,null,"Secondary Postural Support",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,"Select after category..."]
["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,"Serial #:"]
["Size / Dimension:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ALL Eligibility criteria #’s met **   (A,B,C):"]
["Initials of Previous Client:",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 client :"]
[]
["ESNB \nEquipment # :",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 & dinsinfected?"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Options / Additional Services"]
["Category",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,null,"ALL Eligibility criteria #s met ** (A,B,C)"]
[1]
[2,null," ",null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[3,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.  "]
[]
["ESNB EQUIPMENT NO LONGER IN USE"]
["Equipment",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,"Returning to ESNB?",null,null,null,null,null,null,null,null,null,null,"If no, please indicate reason:"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["THERAPIST'S SIGNATURE"]
[]
[null,"By signing and dating this request, I confirm that I have completed an assessment on the above noted client with the MAELP equipment noted above, 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,"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,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\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,{"$f":"Cover!$H$22","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!$H$24","v":0}]
[]
[]
[]
["Client name:",null,null,null,null,null,null,{"$f":"Cover!$H$22","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card #:",null,null,null,null,null,null,null,{"$f":"Cover!$H$24","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, 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,"1.",null,"The equipment provided to me is the property of Social Development and is being loaned to me for as long as it is required.  At such a time that the equipment is replaced or that I am no longer eligible for the equipment as per the parameters of the program, I or someone on my behalf 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 supplier."]
[null,"3.",null,"Repairs and maintenance will be provided at no cost by the Mobility and Adaptive Equipment Loan 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,"All installation, service, maintenance, repairs, and assembly/disassembly must be completed by an authorized service supplier.  "]
[null,"5.",null,"This equipment must be operated safely at all times."]
[null,"6.",null,"This equipment must not be abused or misused in any way."]
[]
[]
[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,"Witness3"]
[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"]
[]
[]
["A witness is only required when the client signs with an \"X\". A legal guardian's signature is only required when the client is unable to sign themsleves."]
["An administrator of a residential 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."]
[]
["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."]

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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,{"$f":"Cover!$H$22","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"Cover!$H$24","v":0}]
[]
[]
[]
["Client name:",null,null,null,null,null,null,{"$f":"Cover!$H$22","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Health Card #:",null,null,null,null,null,null,null,{"$f":"Cover!$H$24","v":0}]
[]
["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 clients’ 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, and/or provide the answers to the Essential Details questions specific to any Specialized Option(s) requested."]

{"sheet":"L12","index":10,"n_rows":20,"n_cols":2,"rows_kept":20,"cut":false,"hidden":true,"merged":[]}
["List1"]
["Folding manual wheelchair","FoldingManWheel"]
["Rigid manual wheelchair","RigidManWheel"]
["Specialty manual wheelchair","Specialtymanualwheelchair"]
[]
["FoldingManWheel"]
["Limited adj. / Fixed axle"]
["Adjustable Axle"]
["Specialized Material - Adj. Axle"]
[]
["RigidManWheel"]
["Adjustable Rigid"]
["Specialized  Material Rigid Adj"]
[]
["Specialtymanualwheelchair"]
["Tilt in Space - 0 - 30 degrees"]
["Tilt in space - over 30 degrees"]
["Bariatric "]
["Adaptive stroller"]
["Early intervention stroller"]

{"sheet":"L34","index":11,"n_rows":31,"n_cols":2,"rows_kept":31,"cut":false,"hidden":true,"merged":[]}
["List3"]
["Standard options - manual","StandOpsMan"]
["Specialized options - manual","SpecOptManu"]
["Additional services - manual","AdditonalServMan"]
[]
["StandOpsMan"]
["Elevating/articulating leg/foot rests"]
["Medical device holder"]
["Specialized hand rims-under $500"]
["Specialized lightweight wheels/spokes-under $500"]
["Suspension Forks"]
["Unoccupied Transit Option - over $400"]
["6-Wheeled Configuration"]
[]
[]
[]
["SpecOptManu"]
["Custom made options"]
["Dynamic Frame components"]
["Frame customization"]
["Manually reclining back"]
["One arm drive"]
["Other options-over $500"]
["Power Tilt"]
["Power Assist for client"]
["Specialized hand rims-over $500"]
["Specialized wheels/spokes-over $500"]
[]
["AdditonalServMan"]
["Modifications"]
["Rentals"]

{"sheet":"L56","index":12,"n_rows":7,"n_cols":2,"rows_kept":7,"cut":false,"hidden":true,"merged":[]}
["List5"]
["Power wheelchair","PowerWheel"]
[]
["PowerWheel"]
["Basic Power Wheelchair"]
["Rehab Power Wheelchair"]
["Bariatric pw/c Basic and Rehab"]

{"sheet":"L78","index":13,"n_rows":63,"n_cols":2,"rows_kept":63,"cut":false,"hidden":true,"merged":[]}
["List 7"]
["Standard options - Power","StandardOptPow"]
["Basic pw/c -Specialized Options ","BasicPWC"]
["Rehab pw/c - Specialized Options","RehabPWC"]
["Bariatric pw/c -Specialized Options","BariPWC"]
["Additional services - Power","AddServPower"]
[]
["StandardOptPow"]
["Manual elevating leg/footrests"]
["Medical device holder"]
["Suspension forks"]
["Unoccupied transit - over $400"]
[]
[]
["BasicPWC"]
["Custom made options"]
["Dynamic frame components"]
["Frame customization"]
["Manually reclining back"]
["Other options over $500"]
["Specialized switches/buttons"]
["Tracking control/enhanced steering"]
["Upgraded joystick "]
[]
["RehabPWC"]
["Alternate drive system"]
["Attendant Control"]
["Custom made options"]
["Dynamic frame components"]
["Frame customization"]
["Manually reclining back"]
["Other options over $500"]
["Power elevating leg rest /foot platform"]
["Power elevating seat"]
["Power tilt"]
["Power recline"]
["Power tilt and recline "]
["Specialized switches/buttons"]
["Tracking control/enhanced steering"]
["Upgraded joystick"]
[]
[]
["BariPWC"]
["Alternate drive system"]
["Attendant Control"]
["Custom made options"]
["Dynamic frame components"]
["Frame customization"]
["Manually reclining back"]
["Other options over $500"]
["Power elevating leg rest /foot platform"]
["Power elevating seat"]
["Power tilt"]
["Power recline"]
["Power tilt and recline "]
["Specialized switches/buttons"]
["Tracking control/enhanced steering"]
["Upgraded joystick"]
[]
[]
["AddServPower"]
["Modifications"]
["Rentals"]

{"sheet":"PWCList","index":14,"n_rows":19,"n_cols":2,"rows_kept":19,"cut":false,"hidden":true,"merged":[]}
["PowerWheel"]
["Basic Power Wheelchair","BasicPWCOpts"]
["Rehab Power Wheelchair","RehabPWCOpts"]
["Bariatric pw/c Basic and Rehab","BariatricPWCOpts"]
[]
["BasicPWCOpts"]
["Basic pw/c -Specialized Options "]
["Standard options - Power"]
["Additional services - Power"]
[]
["RehabPWCOpts"]
["Rehab pw/c - Specialized Options"]
["Standard options - Power"]
["Additional services - Power"]
[]
["BariatricPWCOpts"]
["Bariatric pw/c -Specialized Options"]
["Standard options - Power"]
["Additional services - Power"]

{"sheet":"L910","index":15,"n_rows":12,"n_cols":2,"rows_kept":12,"cut":false,"hidden":true,"merged":[]}
["List9"]
["Primary Postural Supports","PrimPostSupp"]
[]
[]
[]
["PrimPostSupp"]
["Back supports"]
["Seat cushions"]
["Seat cushion outside of a wheelchair "]
["Custom made postural supports"]
["Custom configured postural supports"]
["Custom molded postural support"]

{"sheet":"L11-12","index":16,"n_rows":7,"n_cols":2,"rows_kept":7,"cut":false,"hidden":true,"merged":[]}
["List 11"]
["Secondary Postural Support","SecondaryPostSupp"]
[]
["PostSuppOpt"]
["Head support"]
["Upper body support"]
["Lower body support"]

{"sheet":"L13-14","index":17,"n_rows":15,"n_cols":2,"rows_kept":15,"cut":false,"hidden":true,"merged":[]}
["List13"]
["Postural support options","PrimPostSuppOpt14"]
["Additional services","AdditionalServ14"]
[]
["PrimPostSuppOpt14"]
["Additional cushion/cover(s)"]
["Drop base"]
["Foam in place"]
["Heavy duty"]
["Privacy flap"]
["Solid seat insert"]
[]
["AdditionalServ14"]
["Modifications"]
["Rental"]

{"sheet":"L15","index":18,"n_rows":16,"n_cols":2,"rows_kept":16,"cut":false,"hidden":true,"merged":[]}
["List15"]
["Postural support opt.","SecPostSuppOpt15"]
["Additional services","AdditionalServ15"]
[]
[]
["SecPostSuppOpt15"]
["Foam in place"]
["Security buckle (+ pin)"]
["Special lateral supp mounting Hrdwr"]
["Specialized pressure reduction"]
["Specialized head supp mounting hrdwr"]
["Tray accessories"]
[]
["AdditionalServ15"]
["Modifications"]
["Rental"]