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{"name": "labs-test(13).pdf", " {"name": "labs-test(13).pdf", "content_type": "application/octet-stream", "size": 182946, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-e89a69aa-642f-4555-b00a-51e2f5d375fc"}...
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{"name": "labs-test(12).pdf", " {"name": "labs-test(12).pdf", "content_type": "application/octet-stream", "size": 182946, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-de51393f-cb59-4ad7-a0cc-64c4c254a9b5"}...
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{"name": "labs-scannedreporttest12.pdf {"name": "labs-scannedreporttest12.pdf", "content_type": "application/octet-stream", "size": 182946, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-8375e979-d5d3-4e42-97d6-20dd4ebf0801"}...
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{"name": "labs-scannedreporttest12(1). {"name": "labs-scannedreporttest12(1).pdf", "content_type": "application/octet-stream", "size": 182946, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-4b74f169-91d2-4c9d-9b17-b84a06b064db"}...
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labs-fd5827d7-7ebd-4cc4-9a06-6c7e3a846f7e.pdf
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{"name": "labs-fd5827d7-7ebd-4cc4-9a06 {"name": "labs-fd5827d7-7ebd-4cc4-9a06-6c7e3a846f7e.pdf", "content_type": "application/octet-stream", "size": 642692, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-4dd7f07d-3783-4dff-a646-c2139b38fdd6"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10)"}...
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labs-f5c83c45-d718-4117-bb7c-9894dba18aef.pdf
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{"name": "labs-f5c83c45-d718-4117-bb7c {"name": "labs-f5c83c45-d718-4117-bb7c-9894dba18aef.pdf", "content_type": "application/octet-stream", "size": 647630, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-fa7ff58b-59ac-416b-b045-174ec5c219f3"}...
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{"status": "completed", "conte {"status": "completed", "content": "Chemistry Specialty Requisition\nCH-0311(Rev2023-04)\nLaboratory Medicine and Pathology\nEdmonton Zone Laboratory Services\nClient Response Centre 780-407-7484\nFasting\n# of hrs\nSpecimen Type\nBlood \u00a3 Serum \u00a3 Plasma\n\u00a3 Whole blood\n\u00a3 m\\Microcollection\nUrine / Feces \u00a3 Random \u00a3 24 hr \n\u00a3 Timed, other ________________\nTotal volume __________________\nStart time/date ________________\nStop time/date ________________\nOther ________________________\nBill Type\n CPL \u00a3 Alberta Health Care OT \u00a3 Out of Prov\nCCO \u00a3 Alberta Health Care Third Party XX \u00a3 Pre-paid\nCO \u00a3 DynaLIFEDX PB \u00a3 Patient Bill\nCo. name ________________________________________________\nAddress _________________________________________________\nClient # __________________________________________________\nSpecimen Event Type\nIA \u00a3 AUXILIARY HC \u00a3 HMCARE\nIP \u00a3 IN PT ST \u00a3 STAFF\nOP \u00a3 OUT PT EN \u00a3 ENVIRON\nAP \u00a3 AMBUL WCB \u00a3 WORKER'S \n COMP\nVITAMIN D\n25VD o 25-Hydroxy Vitamin D\nTesting that does not meet the criteria \nlisted below will NOT be preformed:\n(Check all that are appropriate for your \npatient)\no\nMetabolic bone diseases\no Abnormal blood calcium\no Malabsorption syndromes\n(celiac disease, small intestine surgery,\nanticonvulsant agents)\no Chronic renal disease\no Chronic liver disease\nANTI-NUCLEAR ANTIBODY SCREEN\nANA o Anti-Nuclear Antibody Screen\nANA lacks specificity (high false positive \nrate) as a diagnostic test in the absence \nof relevant clinical symptoms. \nAt least two of the criteria listed below \nshould be identified. \no\nPhotosensitive (\"lupus\") rash\no Arthritis\no Myositis\no Oral ulcers\no Pleurisy or pericarditis\no Glomerulonephritis\no Hemolytic anemia, thrombocytopenia,\nneutropenia or lymphopenia\no Seizures or psychosis\no Raynaud's phenomenon\no Scleroderma skin changes\no Alopecia Areata\no Sicca (dry mouth/dry eyes)\no Suspected Juvenile Arthritis\nBIOCHEMICAL GENETICS\nStrict attention to recommended specimen \ncollection procedures is required. Information \ncan be obtained from \"Guide to Lab Services\" \nor by calling Client Response Centre.\nTPN (last 72 h) o Yes o No\nTransfusion (last 90 days) o Yes o No \nPlasma\nAAQ o Amino Acid Quantitation\nBTDQ o Biotinidase\nBlood\nACBS o Acylcarnitine, Blood Spot\nLCARA o Arylsulfatase A\nLCARB o Arylsulfatase B\nFABRY o Fabry\nGALSC o Galactosemia Screen\nGAUCH o Gaucher\nBGALA o GM1 Gangliosidosis\nPOMPE o Pompe\nKRABBE o Krabbe\nUrine\nUAAQ o Amino Acid Quantitation\nUCYST o Cystinuria Screen\nMPSCS o Mucopolysaccharide Screen\nOLIGO o Oligosaccharide Screen\nORGLC o Organic Acids\nSUGID o Sugar Screen\nUSULF o\tSulfite\tScreen\nStool\nFRED o Reducing Substances\nCSF\nSFAAQ o Amino Acid Quantitation\nTRACE ELEMENTS\nStrict attention to recommended specimen collection procedures \nis required. Information can be obtained from \"Guide to Lab \nServices\" or by calling Client Response Centre.\nPlease complete the following\nEnvironmental exposure to certain trace elements either \noccupationally or in food / medications can cause elevated \ntrace element concentrations. Previous administration \nof GADOLINIUM- or BARIUM-CONTAINING CONTRAST \nMEDIA is known to cause interference with trace elements \ndeterminations.\nOccupational exposure o Yes o No\nDate of exposure ______________ Time of exposure ________\nTrace elements suspected _______________________________\nSerum Whole Blood Urine\nAluminium o ALU o UAL\nAntimony o WBSB o USB\nArsenic o WBAS o UAS\nBarium o SBA o UBA\nBeryllium o SBE o UBER\nBismuth o UBI\nCadmium o BCDM o UCD\nChromium o SCRM o UCRM\nCobalt o WBCO o UCOB\nCopper o SCU o UCU\nLead o WBPB o UPB\nManganese o BMN o UMN\nMercury o WBHG o UHG\nMolybdenum o WBMO\nNickel o NIK o UNIK\nSelenium o SSE o USEL\nThallium o WBTL o UTHAL\nZinc o SZN o UZN\nOTHER TESTS\nScanning Label or Accession # (lab only)\nProvider(s)\n Patient\nCollection\nPHN\nExpiry: ________\nDate of Birth (dd-Mon-yyyy)\nLegal Last Name Legal First Name Middle Name\nAlternate\tIdentifier Preferred Name o Male o Female\no Non-binary o Prefer not to disclose\nPhone\nAddress City/Town Prov Postal Code\nAuthorizing Provider Name (last, first, middle) Copy to Name (last, first, middle) Copy to Name (last, first, middle)\nAddress Phone Address Address\nCC Provider ID CC Submitter ID Legacy ID Phone Phone\nClinic Name Clinic Name Clinic Name\nDate (dd-Mon-yyyy) Time (24 hr) Location Collector ID\n578788878\n1998-12-11\nKash\nDiv\nMequanent\nTed\n52 Castlefall Way NE\nCaglary\nChoose Province\nT3J1M7\n1"}...
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labs-f1a5a09d-2fb9-4753-b612-fa9fb710d262.pdf
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{"name": "labs-f1a5a09d-2fb9-4753-b612 {"name": "labs-f1a5a09d-2fb9-4753-b612-fa9fb710d262.pdf", "content_type": "application/octet-stream", "size": 988695, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-951f5b8a-28ba-4f9b-9f90-2873b58c87fa"}...
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{"status": "completed", "conte {"status": "completed", "content": "Preferred Facility Inpatient Location\nPatient Phone Number (Cell # preferred) Patient Address\nCity Postal Code WCB Claim Number\nOrdering Provider Name Provider ID Department ID\nProvider Fax Provider Phone Contact Number for Critical Test Results\nProvider Address/Location City Postal Code\nLocum \uf06f No \uf06f Yes \u25ba Primary Provider Name and Provider ID _______________________________________\nSignature Date (dd-Mon-yyyy) Copy to Provider (last,first and middle) Copy to Fax\nRequested Procedure Research Study \uf06f No \uf06f Yes\nStudy Name: ___________________ Study #: ________\nReason for Exam \nClinical question to be answered\nRelevant Previous Imaging Studies\nModality Location Date (dd-Mon-yyyy) Attached copy \uf06f No \uf06f Yes\n00033(Rev2022-08)\nComputed Tomography \n(CT) Request\nCurrent Patient Condition No Yes Weight _______ \uf06f Kg \uf06f lbs Height _______ \uf06f cm \uf06f in\nPregnant \uf06f n/a \uf06f \uf06f Date of LMP (dd-Mon-yyyy)\nPediatric/Special Needs \uf06f \uf06f Requires sedation \uf06f No \uf06f Yes \uf06f Anesthesia\nIsolation Precautions \uf06f \uf06f Specify:\nDiabetic \uf06f \uf06f Metformin (Glucophage) \uf06f No \uf06f Yes (Patient may have to stop\nMetformin for 48 hours post contrast media injection)\nAsthma \uf06f \uf06f n/a\nHistory of a Severe anaphylaxis reaction \uf06f \uf06f Carries an Epipen \uf06f No \uf06f Yes\nAllergies (include any reaction to contrast media) \uf06f \uf06f Specify:\nOrgan Transplant \uf06f \uf06f Specify:\nPrevious chemotherapy \uf06f \uf06f Specify:\nPower Compatible Port/PICC/CVC insitu \uf06f \uf06f Specify:\nMechanical lift/Transfer required \uf06f \uf06f Specify:\nVascular Disease (Hypertension, HF, etc) \uf06f \uf06f Specify:\nRenal Disease or Solitary Kidney \uf06f \uf06f Specify:\nRenal Insufficiency \uf06f \uf06f Date of last GFR Result (dd-Mon-yyyy)\nOn Dialysis \uf06f No \u25ba \uf06f Hemodialysis \u25ba \uf06f Acute Renal Failure\n \uf06f Yes \uf06f Peritoneal Dialysis \uf06f End Stage Renal Disease\nSerum Creatinine (within 90 days) ________________ GFR (within 90 days) _______ Date (dd-Mon-yyyy) __________\nDepartment Use Only\nDate Received (dd-Mon-yyyy) Time Received (hh:mm) Date of Appointment (dd-Mon-yyyy) Time of Appointment (hh:mm)\nMore info required \uf06f No \uf06f Yes \u25ba Explain: Protocol: IV Contrast \uf06f No \uf06f Yes\nOral Contrast \uf06f No \uf06f Yes\nPriority \uf06f OP1 \uf06f OP2 \uf06f OP3 \uf06f OP4, Specify date: Radiologist\nnAll fields must be completed in order to process request\nn Fax to Diagnostic Imaging; fax numbers listed at\nhttp://www.albertahealthservices.ca/diagnosticimaging\nn Urgent/Emergent requests must be discussed by direct\nconsultation with a radiologist\nLast Name (Legal) First Name (Legal)\nPreferred Name /box1 Last /box1 FirstDOB(dd-Mon-yyyy)\nPHN ULI /box1 Same as PHNMRN\nAdministrative Gender /box1 Male /box1Female\n/box1Non-binary/Prefer not to disclose (X) /box1 Unknown\nCaglary\n4036481926\n1\nDiv\nKash\n578788878\ncalgary\nT1Y6L4\nT3J1M7"}...
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labs-f15363b0-810e-4d03-976f-d0db1d049379.pdf
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{"name": "labs-f15363b0-810e-4d03-976f {"name": "labs-f15363b0-810e-4d03-976f-d0db1d049379.pdf", "content_type": "application/octet-stream", "size": 761847, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-91fa2ddd-e851-4a16-bd9a-0a817fc38a41"}...
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{"status": "completed", "conte {"status": "completed", "content": "Ultrasound Request\nPreferred Facility Inpatient Location\nPatient Phone Number (Cell # preferred) Patient Address\nCity Postal Code WCB Claim Number\nOrdering Provider Name Provider ID Department ID\nProvider Fax Provider Phone Contact Number for Critical Test Results\nProvider Address/Location City Postal Code\nLocum \uf06f No \uf06f Yes \u25ba Primary Provider Name and Provider ID _______________________________________\nSignature Date (dd-Mon-yyyy) Copy to Provider (last,first and middle) Copy to Fax\nRequested Procedure\nReason for Exam \nClinical question to be answered\nRelevant Previous Imaging Studies (Mandatory)\nModality Location Date (dd-Mon-yyyy) Attached copy \uf06f No \uf06f Yes\nn ALL fields must be completed in order to process request\nn Fax to Diagnostic Imaging; fax numbers listed at\nhttp://www\n.albertahealthservices.ca/diagnosticimaging\nn Urgent/Emergent requests must be discussed by direct consultation with\na radiologist\nFollow Up\nStat report requested\n\uf06f No \uf06f Yes (phone/pager):\nPatient follow up \uf06f n/a\n\uf06f In ER \uf06f With GP \uf06f Other (specify):\nCurrent Patient Condition Weight \uf06f kg \uf06f lbs Height \uf06f cm \uf06f in\nCondition No Yes If Yes: \nPatient Pregnant \uf06f n/a \uf06f \uf06f Date of LMP:\nContraceptive Use \uf06f \uf06f Specify:\nIsolation Precautions \uf06f \uf06f Specify:\nAllergies \uf06f \uf06f Specify:\nMedications \uf06f \uf06f Specify:\nMechanical lift/ transfer required \uf06f \uf06f Specify:\nResearch Study \uf06f \uf06f Study Name: Study #:\nObstetrical History (if applicable)\nDescribe: G T P\nL A\nLMP (dd-Mon-yyyy)\nDepartment Use Only\nAppointment Priority \uf06f 24 hr \uf06f 1 week \uf06f Next Avail. \uf06f Other (specify):\nDate Received (dd-Mon-yyyy) Time Received (hh:mm) Date of Appointment (dd-Mon-yyyy) Time of Appointment (hh:mm)\nLast Name (Legal) First Name (Legal)\nPreferred Name /box1 Last /box1 FirstDOB(dd-Mon-yyyy)\nPHN ULI /box1 Same as PHNMRN\nAdministrative Gender /box1 Male /box1Female\n/box1\nNon-binary/Prefer not to disclose (X) /box1 Unknown\n09922 (Rev2022-08) \nKash\nDiv\n1998-12-11\n578788878\n4032354147\nCalgary\n52 Castlefall Way NE\nCaglary\nT3J1M7"}...
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labs-ef2fa768-06c1-4afc-97df-9d305a5d4ca5.pdf
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash nss\nDiv nss\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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labs-e85d46da-a502-4133-a1a1-13a50628fb86.pdf
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n1998-12-11\n578788878\nWhite\n52 Castlefall Way NE\nCaglary\nT3J1M7\nCalgary\n4032354147\nChoose Province\nDavid"}...
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labs-e7b061d2-1804-4d97-8eb4-a877035b549f.pdf
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \n65\n1.5\n3\nKash abcder\nDiv ajk\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE s\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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/home/sid/xevyo/open-webui-dev/backend/data/upload /home/sid/xevyo/open-webui-dev/backend/data/uploads/12842118-c110-434d-897d-b3bb283b5616_labs-e7b061d2-1804-4d97-8eb4-a877035b549f.pdf...
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labs-e77203c4-ffe4-451a-b732-d5366156f88e.pdf
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4754c848f36383fad536edcda2271e5029845fbe82cb77a758 4754c848f36383fad536edcda2271e5029845fbe82cb77a7586fad267ad4328f...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv ss\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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labs-e5d49758-6b6e-4f87-a1cf-2c4e2430245c.pdf
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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labs-e53ea416-415e-457e-a879-3dc2c8a78bf6.pdf
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{"status": "failed", "error {"status": "failed", "error": "Stream has ended unexpectedly"}...
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labs-e37eea06-398f-4ed2-9b44-04b84d42f36b.pdf
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{"status": "completed", "conte {"status": "completed", "content": "Referring Physician\nDate:\nPhysician Name:\nPhysician Address:\nPhysician ID:\nPhysician Signature:\nPatient Information\nPhysician Email:\nUrgency\n24 hrs 48 hrs 72 hrs 1 Week\n#250-8500 Blackfoot Trail SE\nCalgary, AB T2J 7E1\nTel: 403-879-7911\nwww.chestpainclinic.ca\nChest Pain Rating\n1 2 3 4 5 6 7 8 9 10\nMedical History \nCheck All That Apply\n Abnormal ECG\nAtrial Fibrillation\nAbnormal Coronary CT\nHistory of Myocardial Infarction\nHistory of Heart Failure\nPalpitation\nAdditional Information / Report Attached\n ECG Lab Stress Test Echo MPI\nCT MRI Holter 24ABP\nFax: 403-879-7899\n Angina Typical Atypical\n History of COPD\nAbnormal Stress Test\nShortness of Breath\nHistory of CABG \nHistory of Valvular Surgery\nObstructive Sleep Apnea\nX-Ray\n Diabetes\nHypertension\nHyperlipidemia\nK\nnown CAD\nSmoker Current Past\n Family History of Heart Disease Peripheral Artery Disease\nCONFIDENTIALITY STATEMENT: Information contained in this communication may be confidential and is intended only for the use of the recipient(s). If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, \ndistribution, or copying of this communication or any of its content is strictly prohibited. If you receive this communication or any of its contents in error please return it to the sender and contact Advanced Cardiology 403.235.4109\nPatient Name:\nPatient PHN Number:\nPatient Address:\nDate of Birth:\nPatient Phone:\nMale Female\n1998-12-11\n578788878"}...
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labs-e14eb61e-4b22-458c-8a4f-0dd9b5a21461.pdf
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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labs-d985c2a5-5c65-4b21-ae75-7a0867a43f74.pdf
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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labs-cfe5d895-b6c3-40b5-a2fd-485121aa184f.pdf
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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labs-cf23d619-3f55-4494-af69-e35149dd8456.pdf
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{"status": "completed", "conte {"status": "completed", "content": "Chemistry Specialty Requisition\nCH-0311(Rev2023-04)\nLaboratory Medicine and Pathology\nEdmonton Zone Laboratory Services\nClient Response Centre 780-407-7484\nFasting\n# of hrs\nSpecimen Type\nBlood \u00a3 Serum \u00a3 Plasma\n\u00a3 Whole blood\n\u00a3 m\\Microcollection\nUrine / Feces \u00a3 Random \u00a3 24 hr \n\u00a3 Timed, other ________________\nTotal volume __________________\nStart time/date ________________\nStop time/date ________________\nOther ________________________\nBill Type\n CPL \u00a3 Alberta Health Care OT \u00a3 Out of Prov\nCCO \u00a3 Alberta Health Care Third Party XX \u00a3 Pre-paid\nCO \u00a3 DynaLIFEDX PB \u00a3 Patient Bill\nCo. name ________________________________________________\nAddress _________________________________________________\nClient # __________________________________________________\nSpecimen Event Type\nIA \u00a3 AUXILIARY HC \u00a3 HMCARE\nIP \u00a3 IN PT ST \u00a3 STAFF\nOP \u00a3 OUT PT EN \u00a3 ENVIRON\nAP \u00a3 AMBUL WCB \u00a3 WORKER'S \n COMP\nVITAMIN D\n25VD o 25-Hydroxy Vitamin D\nTesting that does not meet the criteria \nlisted below will NOT be preformed:\n(Check all that are appropriate for your \npatient)\no\nMetabolic bone diseases\no Abnormal blood calcium\no Malabsorption syndromes\n(celiac disease, small intestine surgery,\nanticonvulsant agents)\no Chronic renal disease\no Chronic liver disease\nANTI-NUCLEAR ANTIBODY SCREEN\nANA o Anti-Nuclear Antibody Screen\nANA lacks specificity (high false positive \nrate) as a diagnostic test in the absence \nof relevant clinical symptoms. \nAt least two of the criteria listed below \nshould be identified. \no\nPhotosensitive (\"lupus\") rash\no Arthritis\no Myositis\no Oral ulcers\no Pleurisy or pericarditis\no Glomerulonephritis\no Hemolytic anemia, thrombocytopenia,\nneutropenia or lymphopenia\no Seizures or psychosis\no Raynaud's phenomenon\no Scleroderma skin changes\no Alopecia Areata\no Sicca (dry mouth/dry eyes)\no Suspected Juvenile Arthritis\nBIOCHEMICAL GENETICS\nStrict attention to recommended specimen \ncollection procedures is required. Information \ncan be obtained from \"Guide to Lab Services\" \nor by calling Client Response Centre.\nTPN (last 72 h) o Yes o No\nTransfusion (last 90 days) o Yes o No \nPlasma\nAAQ o Amino Acid Quantitation\nBTDQ o Biotinidase\nBlood\nACBS o Acylcarnitine, Blood Spot\nLCARA o Arylsulfatase A\nLCARB o Arylsulfatase B\nFABRY o Fabry\nGALSC o Galactosemia Screen\nGAUCH o Gaucher\nBGALA o GM1 Gangliosidosis\nPOMPE o Pompe\nKRABBE o Krabbe\nUrine\nUAAQ o Amino Acid Quantitation\nUCYST o Cystinuria Screen\nMPSCS o Mucopolysaccharide Screen\nOLIGO o Oligosaccharide Screen\nORGLC o Organic Acids\nSUGID o Sugar Screen\nUSULF o\tSulfite\tScreen\nStool\nFRED o Reducing Substances\nCSF\nSFAAQ o Amino Acid Quantitation\nTRACE ELEMENTS\nStrict attention to recommended specimen collection procedures \nis required. Information can be obtained from \"Guide to Lab \nServices\" or by calling Client Response Centre.\nPlease complete the following\nEnvironmental exposure to certain trace elements either \noccupationally or in food / medications can cause elevated \ntrace element concentrations. Previous administration \nof GADOLINIUM- or BARIUM-CONTAINING CONTRAST \nMEDIA is known to cause interference with trace elements \ndeterminations.\nOccupational exposure o Yes o No\nDate of exposure ______________ Time of exposure ________\nTrace elements suspected _______________________________\nSerum Whole Blood Urine\nAluminium o ALU o UAL\nAntimony o WBSB o USB\nArsenic o WBAS o UAS\nBarium o SBA o UBA\nBeryllium o SBE o UBER\nBismuth o UBI\nCadmium o BCDM o UCD\nChromium o SCRM o UCRM\nCobalt o WBCO o UCOB\nCopper o SCU o UCU\nLead o WBPB o UPB\nManganese o BMN o UMN\nMercury o WBHG o UHG\nMolybdenum o WBMO\nNickel o NIK o UNIK\nSelenium o SSE o USEL\nThallium o WBTL o UTHAL\nZinc o SZN o UZN\nOTHER TESTS\nScanning Label or Accession # (lab only)\nProvider(s)\n Patient\nCollection\nPHN\nExpiry: ________\nDate of Birth (dd-Mon-yyyy)\nLegal Last Name Legal First Name Middle Name\nAlternate\tIdentifier Preferred Name o Male o Female\no Non-binary o Prefer not to disclose\nPhone\nAddress City/Town Prov Postal Code\nAuthorizing Provider Name (last, first, middle) Copy to Name (last, first, middle) Copy to Name (last, first, middle)\nAddress Phone Address Address\nCC Provider ID CC Submitter ID Legacy ID Phone Phone\nClinic Name Clinic Name Clinic Name\nDate (dd-Mon-yyyy) Time (24 hr) Location Collector ID\n578788878\n1998-12-11\nKash\nDiv\nMequanent\nTed\n52 Castlefall Way NE\nCaglary\nChoose Province\nT3J1M7\n1"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash ctg\nDiv cty\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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{"status": "completed", "conte {"status": "completed", "content": "Laboratory information Centre: 403-770-3600 https://www.albertaprecisionlabs.ca \nREQ9042COL Rev. 1.02 \nCOLPOSCOPY PATHOLOGY REQUISITION Scanning Label or Accession # (lab only) \nPatient \nPHN \nExpiry: \nDate of Birth (dd-Mon-yyyy) \nLegal Last Name Legal First Name Middle Name \nAlternate Identifier Preferred Name Male Female Phone \n Non-binary Prefer not to disclose \nAddress City/Town Prov Postal Code \nProvider (s) Authorizing Provider Name (last, first, middle) Copy to Name (last, first, middle) Copy to Name (last, first, middle) \nAddress Phone Address Address \nCC Provider ID CC Submitter ID Legacy ID Phone Phone \nClinic Name Clinic Name Clinic Name \nCollection Date (dd-Mon-yyyy) Time (24 hr) Location Collector ID \nGYNECOLOGY HISTORY PRIOR TREATMENT FIRST COLPOSCOPY VISIT\n \nPREVIOUS PAP RESULT: _______________________________________ \nL\nNMP: __ __ __ __ / __ __ / __ __ Cycle: Every ___________ days \n Y Y Y Y M M D D \n \n __ __ __ __ / __ __ / __ __ \n Y Y Y Y M M D D \n\uf06f Cryotherapy\n\uf06f Chemotherapy\n\uf06f Laser \uf06f LEEP\n\uf06f XRT \uf06f Cone\n\uf06f Other _______________\n \n\uf06f YES \uf06f NO\n\uf06f Hysterectomy (No Cervix)\n\uf06f Immunocompromised\n\uf06f IUD\n\uf06f Pregnant _________ weeks\n \n\uf06f Post Partum ________ weeks\n\uf06f Breast feeding\n\uf06f Menopausal\n\uf06f OCP \uf06f HRT \n \nCOLPOSCOPIC IMPRESSION \n\uf06f NEGATIVE \uf06f HPV / LSIL \uf06f HSIL\n* Each specimen container must be labelled with the patient's full first and last name and the exact specimen site.\n \n\uf06f BIOPSY \uf0a1 Punch \uf0a1 Cone \uf0a1 Leep LAB USE ONLY \nGROSS DESCRIPTION: \nBiopsy consists of fragments measuring: mm greatest Location: _____ o'clock \uf06f Cervix \uf06f Vagina \uf06f Vulva \uf06f Other: __________ \n\uf06f BIOPSY \uf0a1 Punch \uf0a1 Cone LAB USE ONLY \nGROSS DESCRIPTION: \nBiopsy consists of fragments measuring: mm greatest Location: _____ o'clock \uf06f Cervix \uf06f Vagina \uf06f Vulva \uf06f Other: __________ \n\uf06f BIOPSY \uf0a1 Punch \uf0a1 Cone LAB USE ONLY \nGROSS DESCRIPTION: \nBiopsy consists of fragments measuring: mm greatest Location: _____ o'clock \uf06f Cervix \uf06f Vagina \uf06f Vulva \uf06f Other: __________ \n\uf06f BIOPSY \uf0a1 Punch \uf0a1 Cone LAB USE ONLY \nGROSS DESCRIPTION: \nBiopsy consists of fragments measuring: mm greatest Location: _____ o'clock \uf06f Cervix \uf06f Vagina \uf06f Vulva \uf06f Other: __________ \n\uf06f CURETTINGS \uf06f BIOPSY LAB USE ONLY \nGROSS DESCRIPTION: \n \nBiopsy consists of fragments measuring: mm greatest \uf06f Endocervix \uf06f Endometrium\n\uf06f CURETTINGS \uf06f BIOPSY LAB USE ONLY \nGROSS DESCRIPTION: \nBiopsy consists of fragments measuring: mm greatest \uf06f Endocervix \uf06f Endometrium\n578788878\n1998-12-11\nKash\nDiv\n\u25a0\n52 Castlefall Way NE\nCaglary\nChoose Province\nT3J1M7\nMequanent\nTed\n1"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash abc\nDiv\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash jf\nDiv af\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash abcdks\nDiv alien\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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labs-9f904d45-7f24-4063-b213-3c288cf67214.pdf
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash abc\nDivgfbgb\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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labs-99b61b01-fad2-4fd3-8e2f-234142960471.pdf
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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labs-94533c10-6303-4827-bcb8-81d0f0152253.pdf
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{"status": "completed", "conte {"status": "completed", "content": "20897(Rev2024-03) Page 1 of 4\nScanning Label or Accession # (lab only)\nProvider(s) Patient\nCollection\nPHN\nExpiry: ________\nDate of Birth (dd-Mon-yyyy)\nLegal Last Name Legal First Name Middle Name\n$OWHUQDWH,GHQWL\u00bfHU Preferred Name \u2020 Male \u2020 Female\n\u2020 Non-binary \u2020 Prefer not to disclose\nPhone\nAddress City/Town Prov Postal Code\nAuthorizing Provider Name ODVW\u00bfUVWPLGGOH\f Copy to Name ODVW\u00bfUVWPLGGOH\f Copy to Name ODVW\u00bfUVWPLGGOH\f\nAddress Phone Address Address\nCC Provider ID CC Submitter ID Legacy ID Phone Phone\nClinic Name Clinic Name Clinic Name\nDate (dd-Mon-yyyy) Time KU\f Location Collector ID\nMolecular Genetics Laboratory\nCancer and Endocrine NGS Requisition\nFor detailed testing information, refer to APL Genetics & Genomics Webpage \nhttp://ahsweb.ca/lab/if-lab-genetics-and-genomics and APL Test Directory \nhttp://ahsweb.ca/lab/apl-td-lab-test-directory\nGenetic Counsellor/Clinic Contact Name (last, fi rst) Phone\nSpecimen\n\uf06f Whole Blood in EDTA tube \uf06f Extracted DNA \uf06f Fluid, amniotic*\n\uf06f Tissue, chorionic villi* \uf06f Cord blood* \uf06f Other (specify) ____________\n*If specimen type is prenatal or cord blood, maternal specimen must be collected for maternal cell contamination studies\nHealth Care Provider Important Information \n1. All sections of the requisition must be completed.\n2. By providing this requisition to the patient/family, the health care provider confi rms that they have reviewed the\npre-test counselling information (available on the Genetics & Genomics website) with the patient/family, and the\npatient/family consents to testing.\n3. Direct patient to take requisition to a local blood collection location to have blood specimen drawn.\nBilling Information: Must be completed if the patient does not have a valid \nAlberta Personal Heath Number\nGenetic testing is not covered by inter-provincial billing agreements. Alberta Precision Laboratories (APL) will bill a \nprovincial medical services plan provided there is a letter of pre-approval received with the requisition or Institutional \nBilling information provided below. By completing the Institutional Billing section, the health care provider confi rms \nthey have obtained any necessary pre-approval. For patient pay, contact the testing laboratory.\nInstitutional Billing Information (if pre-approval letter not attached)\nAddress\nContact Name (last, fi rst)\nPhone Fax\nMGL Use Only\nPatient Number Family Number Received Quantity\n1998-12-11\n52 Castlefall Way NE\nCaglary\nChoose Province\nT3J1M7\nDavid\nWhite\nKash\nDiv\n578788878 20897(Rev2024-03) Page 2 of 4\nMolecular Genetics Laboratory\nCancer and Endocrine NGS Requisition\nSection I - Reason for Testing (Select one only)\n\uf06f Confi rmation of Diagnosis \n Patient has signs or symptoms of the disease / disorder.\n\uf06f Presymptomatic or Predictive Testing \n \nPatient does not presently have symptoms; positive family history\n\uf06f Carrier Testing. \n No symptoms; at risk of being a carrier of a recessive disorder\n\uf06f Required for Family Study \n\uf06f Prenatal Testing \n\uf06f Other _____________________________________\nSection II - Family History of Indicated Disease\n\uf06f Unknown family history\n\uf06f No known family history \n\uf06f Possible family history\nDocumented family history\n\uf06f Clinical Diagnosis ONLY\n\uf06f Molecular Diagnosis \n(provide a copy of the familial variant \n report and complete information in Section V)\nIs RUSH testing needed? \uf06f Yes (provide details below)\n\uf06f Results will alter the immediate management and/or treatment of this patient (specify) _______________________\n\uf06f Results will impact an ongoing pregnancy (provide EDD, and procedure date if applicable) _____________________________\nIf RUSH testing is required, please provide a target date (dd-Mon-yyyy) (required) ________________________________\nNote: TAT is a minimum of 4 weeks. \nSection III - Patient Clinical Information \nSex at birth \uf06f Female \uf06f Male \uf06f Unknown\nDate of last chemotherapy (if applicable) \uf067\uf020 \uf020Date (dd-Mon-yyyy) ______________________\nHas this patient received a blood product in the preceding three months? \n\uf020\uf020\uf020\uf020\uf020\uf020\uf020\uf020\uf020\uf020\uf020\uf020\uf020\uf020\uf020\uf020\uf020\uf020\uf020 \uf06f Yes indicate blood product _____________________________\nHas the patient had a bone marrow transplant? \uf06f Yes \n (Blood is an incompatible specimen type)\nPlease provide any relevant information regarding your patient's clinical presentation (ex. tumour site, age at diagnosis, multiple \nprimary tumour, pathology, hormone receptors)\nIf applicable, IHC result (required for Lynch testing) ________________________________________________________________ \nHas the patient had BRCA 1/2 testing of tumour tissue? _________________________________________________________\nSection IV - Pedigree (Provide any relevant family history details, with family member names, ages, and diagnoses included as applicable. If more space \nis required, attach a separate sheet.)\nPatient Ethnicity/Ancestry ____________________________________\nLast Name (Legal) First Name (Legal)\nPHN\nKash\nDiv\n578788878 20897(Rev2024-03) Page 3 of 4\nSection V - Specifi c Variant Testing\nComplete this section only if you are requesting testing for a variant previously identifi ed in the family. \nSpecifi c variant testing is available for all genes available on the panels listed below.\n\uf06f\uf020Inherited Cancer and Endocrine Gene Panels, Specifi c Variant\nGene Mutation/Variant\nRelationship to index patient _______________________________________________\nWhat is the phenotype/presentation in the index patient? _______________________________________________\nOther family members previously tested in MGL \uf06f No \uf06f Yes \u25bc\nINDEX patient name MGL Reference Number\nWhich laboratory performed the proband testing? \uf06f Calgary \uf06f Edmonton \uf06f Other (specify) _____________\nTesting a positive control is recommended if the proband testing was performed at another lab.\nA clear copy of the test report on a family member is required if the testing was performed at another laboratory\nSection VI - Cancer and Endocrine NGS Panel Requests\nBreast, Ovarian and Prostate Cancers\n\uf06f Breast/Ovarian/Prostate Cancer Panel \nEndocrine Disorders\n\uf06f Endocrine Neoplasia Panel\n\uf06f Paraganglioma/Pheochromocytoma Predisposition Panel \n\uf06f Renal Cancer Panel\nGastrointestinal Cancers\n\uf06f Gastrointestinal/Polyposis Panel \n\uf06f Gastrointestinal Stromal Tumor Panel\n\uf06f Lynch Syndrome Panel \n\uf06f Pancreatic Cancer Panel \nHematological Cancers\n\uf06f Familial Acute Myeloid Leukemia Panel\n\uf06f Fanconi Anemia and DNA Repair Disorders Panel\nOvergrowth Disorders\n\uf06f Hereditary Multiple Osteochondromatosis Panel \n\uf06f Overgrowth Panel\nPediatric Cancers\n\uf06f Pediatric Cancer Panel \n\uf06f Schwannomatosis Panel \n\uf06f Tuberous Sclerosis \nSkin Cancers\n\uf06f Skin Cancer Panel \n\uf06f Xeroderma Pigmentosum Panel\nMolecular Genetics Laboratory\nCancer and Endocrine NGS Requisition\nLast Name (Legal) First Name (Legal)\nPHN\nKash\nDiv\n578788878 20897(Rev2024-03) Page 4 of 4\nSection VII - Single Gene Test Request\n\uf06f CASR-Related Disorder\n\uf06f Inherited Cancer and Endocrine Single Gene (complete only if panel is not appropriate for patient)\nRequesting test for ___________________________ (indicate the gene) and the presenting phenotype _____________\nRequesting test for ___________________________ (indicate the gene) and the presenting phenotype _____________\nSection IX - Additional Comments\n\uf06f Neurofi bromaosis Type 1 Please indicate if your patient has the following\n\uf020\uf06f Greater than 6 caf\u00e9-au-lait macules greater than 5 mm, postpubertal greater than 15 mm\n\uf020\uf06f Greater than 2 neurofi bromas or 1 plexiform neurofi broma\n\uf020\uf06f Axillary or inguinal freckling \n\uf020\uf06f Optic glioma\n\uf020\uf06f Greater than 2 Lisch nodules\n\uf020\uf06f A distinctive osseous lesion \n\uf020\uf06f A fi rst degree relative with NF1 per the above critera\nIf the patient does not fulfi ll NIH diagnostic criteria for NF1, please provide reason for testing as a comment\n____________________________________________________________________________________________\nSection VIII - Variant Reinterpretation\nComplete this section only if you are requesting reinterpretation of a variant previously identifi ed in the family\nGene Mutation/Variant\nWhat is the clinical phenotype/presentation in the family?\nA clear copy of the test report is required if the testing was preformed at another laboratory\nMolecular Genetics Laboratory\nCancer and Endocrine NGS Requisition\nLast Name (Legal) First Name (Legal)\nPHN\nKash\nDiv\n578788878"}...
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{"status": "completed", "conte {"status": "completed", "content": "Preferred Facility Inpatient Location\nPatient Phone Number (Cell # preferred) Patient Address\nCity Postal Code WCB Claim Number\nOrdering Provider Name Provider ID Department ID\nProvider Fax Provider Phone Contact Number for Critical Test Results\nProvider Address/Location City Postal Code\nLocum \uf06f No \uf06f Yes \u25ba Primary Provider Name and Provider ID ____________________________________\nSignature Date (dd-Mon-yyyy) Copy to Provider (last,first and middle) Copy to Fax\nSTAT report requested \uf06f No \uf06f Yes \u25ba specify phone/pager:\nRequested Procedure \nReason for Exam \nClinical question to be answered\nRelevant Previous Imaging Studies\nModality Location Date (dd-Mon-yyyy) Attached copy \uf06f No \uf06f Yes\n19031 (Rev2022-08)\nNuclear Medicine Request\nPrevious Treatment No Yes If Yes \nChemotherapy \uf06f \uf06f Where: When:\nRadiation Therapy \uf06f \uf06f Anatomical location: When:\nSurgery \uf06f \uf06f Anatomical location: When:\nCurrent Patient Condition No Yes If Yes Weight _____ \uf06f Kg \uf06f lbs Height ____ \uf06f cm \uf06f in\nPregnant \uf06f n/a \uf06f \uf06f Date of LMP: Date of BHCG: \nBreastfeeding \uf06f \uf06f n/a\nPediatric / Special Needs \uf06f \uf06f Requires sedation: \uf06f\n No \uf06f Oral \uf06f IV \uf06f Anesthesia\nIsolation Precautions \uf06f \uf06f Specify Type:\nDiabetes \uf06f \uf06f n/a\nAllergies \uf06f \uf06f Specify:\nMedications \uf06f \uf06f Specify:\nMechanical lift/ transfer required \uf06f \uf06f Specify:\nResearch Study \uf06f \uf06f Study Name: Study number:\nNuclear Medicine Physician Only\nRadiologist Protocol\nDate Received (dd-Mon-yyyy) Time Received (hh:mm) Appointment Date (dd-Mon-yyyy) Appointment Time (hh:mm)\nn All fields must be completed for form to be processed\nn Fax to Diagnostic Imaging; fax numbers listed at\nhttp://www\n.albertahealthservices.ca/diagnosticimaging\nn Urgent/Emergent requests must be discussed by direct\nconsultation with the radiologist\nLast Name (Legal) First Name (Legal)\nPreferred Name /box1 Last /box1 FirstDOB(dd-Mon-yyyy)\nPHN ULI /box1 Same as PHNMRN\nAdministrative Gender /box1 Male /box1Female\n/box1\nNon-binary/Prefer not to disclose (X) /box1 Unknown\nKash\nDiv\n1998-12-11\n578788878\n4032354147\nCalgary\n52 Castlefall Way NE\nCaglary\nT3J1M7"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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{"name": "labs-83f3117b-3606-4c2f-97e3 {"name": "labs-83f3117b-3606-4c2f-97e3-1d059ea63555.pdf", "content_type": "application/octet-stream", "size": 648043, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-f25a3ed2-182a-4012-9d2b-99601653f026"}...
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{"status": "completed", "conte {"status": "completed", "content": "Chemistry Specialty Requisition\nCH-0311(Rev2023-04)\nLaboratory Medicine and Pathology\nEdmonton Zone Laboratory Services\nClient Response Centre 780-407-7484\nFasting\n# of hrs\nSpecimen Type\nBlood \u00a3 Serum \u00a3 Plasma\n\u00a3 Whole blood\n\u00a3 m\\Microcollection\nUrine / Feces \u00a3 Random \u00a3 24 hr \n\u00a3 Timed, other ________________\nTotal volume __________________\nStart time/date ________________\nStop time/date ________________\nOther ________________________\nBill Type\n CPL \u00a3 Alberta Health Care OT \u00a3 Out of Prov\nCCO \u00a3 Alberta Health Care Third Party XX \u00a3 Pre-paid\nCO \u00a3 DynaLIFEDX PB \u00a3 Patient Bill\nCo. name ________________________________________________\nAddress _________________________________________________\nClient # __________________________________________________\nSpecimen Event Type\nIA \u00a3 AUXILIARY HC \u00a3 HMCARE\nIP \u00a3 IN PT ST \u00a3 STAFF\nOP \u00a3 OUT PT EN \u00a3 ENVIRON\nAP \u00a3 AMBUL WCB \u00a3 WORKER'S \n COMP\nVITAMIN D\n25VD o 25-Hydroxy Vitamin D\nTesting that does not meet the criteria \nlisted below will NOT be preformed:\n(Check all that are appropriate for your \npatient)\no\nMetabolic bone diseases\no Abnormal blood calcium\no Malabsorption syndromes\n(celiac disease, small intestine surgery,\nanticonvulsant agents)\no Chronic renal disease\no Chronic liver disease\nANTI-NUCLEAR ANTIBODY SCREEN\nANA o Anti-Nuclear Antibody Screen\nANA lacks specificity (high false positive \nrate) as a diagnostic test in the absence \nof relevant clinical symptoms. \nAt least two of the criteria listed below \nshould be identified. \no\nPhotosensitive (\"lupus\") rash\no Arthritis\no Myositis\no Oral ulcers\no Pleurisy or pericarditis\no Glomerulonephritis\no Hemolytic anemia, thrombocytopenia,\nneutropenia or lymphopenia\no Seizures or psychosis\no Raynaud's phenomenon\no Scleroderma skin changes\no Alopecia Areata\no Sicca (dry mouth/dry eyes)\no Suspected Juvenile Arthritis\nBIOCHEMICAL GENETICS\nStrict attention to recommended specimen \ncollection procedures is required. Information \ncan be obtained from \"Guide to Lab Services\" \nor by calling Client Response Centre.\nTPN (last 72 h) o Yes o No\nTransfusion (last 90 days) o Yes o No \nPlasma\nAAQ o Amino Acid Quantitation\nBTDQ o Biotinidase\nBlood\nACBS o Acylcarnitine, Blood Spot\nLCARA o Arylsulfatase A\nLCARB o Arylsulfatase B\nFABRY o Fabry\nGALSC o Galactosemia Screen\nGAUCH o Gaucher\nBGALA o GM1 Gangliosidosis\nPOMPE o Pompe\nKRABBE o Krabbe\nUrine\nUAAQ o Amino Acid Quantitation\nUCYST o Cystinuria Screen\nMPSCS o Mucopolysaccharide Screen\nOLIGO o Oligosaccharide Screen\nORGLC o Organic Acids\nSUGID o Sugar Screen\nUSULF o\tSulfite\tScreen\nStool\nFRED o Reducing Substances\nCSF\nSFAAQ o Amino Acid Quantitation\nTRACE ELEMENTS\nStrict attention to recommended specimen collection procedures \nis required. Information can be obtained from \"Guide to Lab \nServices\" or by calling Client Response Centre.\nPlease complete the following\nEnvironmental exposure to certain trace elements either \noccupationally or in food / medications can cause elevated \ntrace element concentrations. Previous administration \nof GADOLINIUM- or BARIUM-CONTAINING CONTRAST \nMEDIA is known to cause interference with trace elements \ndeterminations.\nOccupational exposure o Yes o No\nDate of exposure ______________ Time of exposure ________\nTrace elements suspected _______________________________\nSerum Whole Blood Urine\nAluminium o ALU o UAL\nAntimony o WBSB o USB\nArsenic o WBAS o UAS\nBarium o SBA o UBA\nBeryllium o SBE o UBER\nBismuth o UBI\nCadmium o BCDM o UCD\nChromium o SCRM o UCRM\nCobalt o WBCO o UCOB\nCopper o SCU o UCU\nLead o WBPB o UPB\nManganese o BMN o UMN\nMercury o WBHG o UHG\nMolybdenum o WBMO\nNickel o NIK o UNIK\nSelenium o SSE o USEL\nThallium o WBTL o UTHAL\nZinc o SZN o UZN\nOTHER TESTS\nScanning Label or Accession # (lab only)\nProvider(s)\n Patient\nCollection\nPHN\nExpiry: ________\nDate of Birth (dd-Mon-yyyy)\nLegal Last Name Legal First Name Middle Name\nAlternate\tIdentifier Preferred Name o Male o Female\no Non-binary o Prefer not to disclose\nPhone\nAddress City/Town Prov Postal Code\nAuthorizing Provider Name (last, first, middle) Copy to Name (last, first, middle) Copy to Name (last, first, middle)\nAddress Phone Address Address\nCC Provider ID CC Submitter ID Legacy ID Phone Phone\nClinic Name Clinic Name Clinic Name\nDate (dd-Mon-yyyy) Time (24 hr) Location Collector ID\n578788878\n1998-12-11\nKash\nDiv\nMequanent\nTed\n52 Castlefall Way NE\nCaglary\nChoose Province\nT3J1M7\n1"}...
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{"name": "labs-81ff39cf-7f71-487a-8aa0 {"name": "labs-81ff39cf-7f71-487a-8aa0-3e0c8919be8a.pdf", "content_type": "application/octet-stream", "size": 1157055, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-37a35b82-9d6d-4465-8cb3-84a6db277753"}...
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{"status": "completed", "conte {"status": "completed", "content": "Referring Physician\nDate:\nPhysician Name:\nPhysician Address:\nPhysician ID:\nPhysician Signature:\nPatient Information\nPhysician Email:\nUrgency\n24 hrs 48 hrs 72 hrs 1 Week\n#250-8500 Blackfoot Trail SE\nCalgary, AB T2J 7E1\nTel: 403-879-7911\nwww.chestpainclinic.ca\nChest Pain Rating\n1 2 3 4 5 6 7 8 9 10\nMedical History \nCheck All That Apply\n Abnormal ECG\nAtrial Fibrillation\nAbnormal Coronary CT\nHistory of Myocardial Infarction\nHistory of Heart Failure\nPalpitation\nAdditional Information / Report Attached\n ECG Lab Stress Test Echo MPI\nCT MRI Holter 24ABP\nFax: 403-879-7899\n Angina Typical Atypical\n History of COPD\nAbnormal Stress Test\nShortness of Breath\nHistory of CABG \nHistory of Valvular Surgery\nObstructive Sleep Apnea\nX-Ray\n Diabetes\nHypertension\nHyperlipidemia\nK\nnown CAD\nSmoker Current Past\n Family History of Heart Disease Peripheral Artery Disease\nCONFIDENTIALITY STATEMENT: Information contained in this communication may be confidential and is intended only for the use of the recipient(s). If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, \ndistribution, or copying of this communication or any of its content is strictly prohibited. If you receive this communication or any of its contents in error please return it to the sender and contact Advanced Cardiology 403.235.4109\nPatient Name:\nPatient PHN Number:\nPatient Address:\nDate of Birth:\nPatient Phone:\nMale Female\n1998-12-11\n578788878"}...
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{"name": "labs-7aec2e5f-5a6d-4812-8996 {"name": "labs-7aec2e5f-5a6d-4812-8996-6e5a778a4a4c.pdf", "content_type": "application/octet-stream", "size": 760344, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-aa78415e-7af7-4612-9d54-51a48967f155"}...
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{"status": "completed", "conte {"status": "completed", "content": "Referring Physician Phone Fax Family Physician\nRequested Procedure \uf02a Left Heart Cath \uf02a Right & Left Heart Cath\n\uf02a PCI \uf02a TAVI Workup \uf02a Previous Bypass Grafts\n\uf02a Other (Specify) \nRequested Physician\n\uf02a or 1st available\nReason for Referral\n\uf02a Stable/Unstable Angina \uf02a CAD \uf02a CHF \uf02a Cardiomyopathy\n\uf02a STEMI \uf02a NSTEMI\n\uf02a Aortic Stenosis Valve Area: cm2 Gradient: mmhg\n\uf02a Valve (Specify Valve) \uf02a AV \uf02a MV \uf02a PV \uf02a TV\n\uf02a Congenital (Specify) \uf02a Other (Specify) \nDocuments Required to Triage(attach)\n\uf02a ECG\n\uf02a History\n\uf02a Copy of cardiac tests\n\uf02a Current Labs (electrolyte\npanel/cbc/creatinine/GFR/ INR)\n\uf02a Medications (provide list)\nCurrent Antithrombotic Therapy\nIs patient using any of the following medications (check all that apply):\uf02a Coumadin \uf02a Dabigatran\n\uf02a Rivaroxaban \uf02a Apixaban \uf02a Enoxaparin \uf02a Fondaparinux \uf02a Heparin\nAnticoagulant InstructionsStop date Last dose taken \nComorbidity Assessment (if performed)\n\uf02a Diabetes \uf02a IDDM \uf02a NIDDM \nOn Metformin? \uf02a Yes \uf02a No\n\uf02a Previous Cath or PCI (most recent): \n\uf02a Previous CABG (most recent): \n\uf02a Previous Valve Surgery:\n\uf02a Mechanical \uf02a Bioprosthetic \uf02a AV \uf02a MV \uf02a TV\n\uf02a Atrial Fibrillation\n\uf02a Apical Thrombus \n\uf02a Cardiomyopathy \uf02a Cardiac Family History \n\uf02a Cerebral vascular disease \uf02a COPD\n\uf02a Dyslipidemia \uf02a History of CHF\n\uf02a Hypertension \uf02a Infective Endocarditis \n\uf02a Peripheral Vascular Disease \uf02a Arrhythmia\n\uf02a Smoker \n\uf02a Renal Insufficiency \uf02a Dialysis \uf02a Hemo \uf02a Peritoneal\nRisk Score\nAngina Class \uf02a o \uf02a i \uf02a ii \uf02a iii \uf02a iv\nHeart Failure Class \uf02a i \uf02a ii \uf02a iii \uf02a iv\nTest Results Risk Score(if performed)\nExcercise ECG \uf02a High \uf02a Intermediate \uf02a Low\nECG \uf02a High \uf02a Intermediate \uf02a Low\nLV\u2008Function \n\uf02a Greater than/equal to 50% \uf02a 35-49% \n\uf02a 20-34% \uf02a Less than 20%\nPerfusion Imaging \uf02a High \uf02a Intermediate \uf02a Low\nStress Echo \uf02a High \uf02a Intermediate \uf02a Low\nCT\u2008Angio \uf02a High \uf02a Intermediate \uf02a Low\n18635(Rev2017-09)\nCardiac Procedures Catheterization Referral\n(Foothills Medical Centre)\nFax: Outpatientreferrals to 403-944-3200 or 403-776-0438\nInpatientreferrals to 403-270-4036\nPatient Location \uf02a Home\n\uf02a Inpatient-unit (Specify) \n\uf02a Patient is aware\n\uf02a Can attend short notice\nGoals of Care Date of Request (yyyy-Mon-dd)\nAllergies Patient Height \n(cm)\nPatient Weight \n(kg)\nIsolation \uf02a Yes \uf02a No\nIf yes, specify \nAbnormal Labs (to be completed by Triage) Creatinine/GFR Grace Score\nTriaged Estimated Urgency \uf02a Urgent Priority \uf02a Urgent \uf02a Semi-Urgent \uf02a Routine\nNotes\nConsulting/Approving Cardiologist Triaged by Date (yyyy-Mon-dd)\n \nKash\nDiv\n1998-12-11\n578788878\n1\n4036481926"}...
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{"name": "labs-79dbc7c8-7c02-417a-93de {"name": "labs-79dbc7c8-7c02-417a-93de-cf9db167d60e.pdf", "content_type": "application/octet-stream", "size": 421055, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-b0e1a6cb-2268-478b-8d1a-962d2aeb99b8"}...
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{"status": "completed", "conte {"status": "completed", "content": "22071(2023-07)\n18637 (2021-10)\nScanning Label or Accession # (lab only)\nProvider(s)\n Patient\nCollection\nPHN\nExpiry: ________\nDate of Birth (dd-Mon-yyyy)\nLegal Last Name Legal First Name Middle Name\nAlternate Identifier Preferred Name o Male o Female\no Non-binary o Prefer not to disclose\nPhone\nAddress City/Town Prov Postal Code\nAuthorizing Provider Name (last, first, middle) Copy to Name (last, first, middle) Copy to Name (last, first, middle)\nAddress Phone Address Address\nCC Provider ID CC Submitter ID Legacy ID Phone Phone\nClinic Name Clinic Name Clinic Name\nDate (dd-Mon-yyyy) Time (24 hr) Location Collector ID\nFor detailed testing information, refer to \nAPL Test Directory (http://ahsweb.ca/lab/apl-td-lab-test-directory)\nAntiphospholipid Syndrome Investigation\nRequisition\nTest(s) \nRequested\nPlease use this requisition only for Lupus anticoagulant / Antiphospholipid Syndrome Investigation. If other\nspecial coagulation testing is required please use the appropriate Hemostasis or Thrombosis Investigations\nrequisition.\nIs the patient currently on any anticoagulants?\n (Select all that apply)\n\uf06f None \uf06f Heparin (unfractionated or low-molecular) \uf06f Vitamin K Antagonist (eg. warfarin)\n\uf06f Other (eg. apixaban, rivaroxaban, fondaparinux, dabigatran, etc) ____________________________________________________\nReason for testing: (select all that apply)\n\uf06f Thromboembolism\n\uf06f Autoimmune Disorder\n\uf06f Fertility Investigation\n\uf06f Pregnancy Loss\n\uf06f Prolonged PTT\n\uf06f Other ________________________________________________________________________________\n\uf06f Lupus Anticoagulant\n\uf06fAnti-cardiolipin Antibody\n\uf06fAnti-beta-2-glycoprotein Antibody\nAnswer all questions\n578788878\n1998-12-11\nKash\nDiv\n52 Castlefall Way NE\nCaglary\nChoose Province\nT3J1M7\nMequanent\nTed\n1"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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{"status": "completed", "conte {"status": "completed", "content": "25268 (2017-06) Side A \nCardiac Re\nhabilitation Referral \nCardiac Rehabilitation mandate is to provide secondary prevention* \nName Address\nULI/PHN male female Phone \nDate of Birth (yyyy-Mon-dd) Alternative Phone\n Language Barrier, language spoken: \nEnglish speaking contact person name and phone: \nDiagnosis / Date (yyyy-Mon-dd) \n Pre-Hab Cardio-Oncology \n NSTEMI AICD \n STEMI Pacemaker \n PCI VAD \n CABG Heart Failure \n Valve Surgery Other (specify) \n Angina \nComments / Other Health Concerns (if no discharge summary provided) \nLocations within Edmonton: \n Glenrose Rehabilitation Hospital Phone 780-735-8206 Fax 780-735-8243 \n Grey Nuns Hospital Phone 780-735-7738 Fax 780-735-7545 \n Mazankowski Heart Institute Phone 780-735-8206 Fax 780-735-8243 \nLocations outside Edmonton (see reverse list and fax numbers) \nN a m e o f P r o g r a m Fax 780- \nReferral made by Physicians to follow \nReferral date (yyyy-Mon-dd) GP\nCardiologist\nOffice Use Only \n* Secondary prevention is defined as the sum total of all interventions, psychological and behavioral, designed to favorably modify an\nindiv\nidual's lifestyle and enhance in adherence and compliance with long term behaviors compatible with minimizing disease progress.\nSecondary prevention occurs after the disease is present, thus, it aims to reduce disease progression, minimize complications and\nreduce further exposure to risk. CACR Guidelines 2009.\n1998-12-11\n578788878 25268 (2017-06) Side B \nCardiac Rehabilitation Programs \nAthabasca Healthcare Centre \nPhysiotherapy Department \nPhone 780-675-6038 Fax 780-675-6045 \nBarrhead Healthcare Centre \nPhysiotherapy Department \nPhone 780-305-3318 Fax 780-674-6773 \nBonnyville Health Centre \nFax 780-815-4226 \nCold Lake Healthcare Centre \nPhysiotherapy Department \nPhone 780-639-6518 Fax 780-639-2255 \nCamrose \nHealthy Living Centre - Edgeworth Centre \nPhone 780-608-8683 Fax 780-608-8693 \nEdson \nHealthcare Center \nPhone 780-712-6861 Fax 780-723-2135 \nFort McMurray \nWood Buffalo Primary Care Network \nPhone 780-788-1765 Fax 780-788-1764 \nFort Saskatchewan \nPhone 780-997-0046 Fax 780-997-0095 \n \nGrande Prairie \nPhone 780-402-8132 or 780-538-7360 \nFax 844-776-3846 \nHigh Level \nPhone 780-841-3304 Fax 780-926-7393 \nHigh Prairie \nChronic Disease Program \nPhone 780-523-6440 ext 6888 \nFax 780-523-6473 \nHinton \nHealth Care Centre \nPhone 780-725-6144 \nFax 780-725-6394 \nLac LaBiche \nPhysiotherapy Department \nPhone 780-623-5921 \nFax 780-623-5904 \nLeduc \nLeduc Cardiac Rehabilitation \nPCN patients only \nPhone 780-986-6624 Fax 780-986-6634 \nLloydminster (Saskatchewan) \nPrairie North Cardiac Rehab \nSTRIDES Cardiac Rehab \nPhone 780-820-6262 Fax 306-820-6256 \nMayerthorpe \nPhysiotherapy Department \nPhone 780-786-2245 ext 151 \nFax 780-786-2023 \nPeace River & Rural Region \nPeace River Community Health Centre \nDiabetes/Cardiac Education \nPhone 780-624-7598 Fax 780-618-3403 \nRed Deer \nPhone 403-343-4508 \nFax 403-343-4419 \nSt. Paul Healthcare Centre \nPhysiotherapy Department \nPhone 780-645-3331 ext 2191 \nFax 780-645-1709 \nWainwright \nCardiac Wellness Program \nPhone 780-806-2029 Fax 780-806-2036 \nWetaskiwin Hospital & Care Centre \nPhysiotherapy Department \nPhone 780-361-4148 Fax 780-312-3755 \nWestlock Healthcare Centre \nPhysiotherapy Department \nPhone 780-350-2010 Fax 780-350-3024 \nWhitecourt Healthcare Centre \nPhysiotherapy Department \nPhone 780-778-5540 ext 241 \nFax 780-778-3852"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n1998-12-11\n578788878\nWhite\n52 Castlefall Way NE\nCaglary\nT3J1M7\nCalgary\n4032354147\nChoose Province\nDavid"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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{"status": "completed", "conte {"status": "completed", "content": "Laboratory information Centre: 403-770-3600 https://www.albertaprecisionlabs.ca \nREQ9042COL Rev. 1.02 \nCOLPOSCOPY PATHOLOGY REQUISITION Scanning Label or Accession # (lab only) \nPatient \nPHN \nExpiry: \nDate of Birth (dd-Mon-yyyy) \nLegal Last Name Legal First Name Middle Name \nAlternate Identifier Preferred Name Male Female Phone \n Non-binary Prefer not to disclose \nAddress City/Town Prov Postal Code \nProvider (s) Authorizing Provider Name (last, first, middle) Copy to Name (last, first, middle) Copy to Name (last, first, middle) \nAddress Phone Address Address \nCC Provider ID CC Submitter ID Legacy ID Phone Phone \nClinic Name Clinic Name Clinic Name \nCollection Date (dd-Mon-yyyy) Time (24 hr) Location Collector ID \nGYNECOLOGY HISTORY PRIOR TREATMENT FIRST COLPOSCOPY VISIT\n \nPREVIOUS PAP RESULT: _______________________________________ \nL\nNMP: __ __ __ __ / __ __ / __ __ Cycle: Every ___________ days \n Y Y Y Y M M D D \n \n __ __ __ __ / __ __ / __ __ \n Y Y Y Y M M D D \n\uf06f Cryotherapy\n\uf06f Chemotherapy\n\uf06f Laser \uf06f LEEP\n\uf06f XRT \uf06f Cone\n\uf06f Other _______________\n \n\uf06f YES \uf06f NO\n\uf06f Hysterectomy (No Cervix)\n\uf06f Immunocompromised\n\uf06f IUD\n\uf06f Pregnant _________ weeks\n \n\uf06f Post Partum ________ weeks\n\uf06f Breast feeding\n\uf06f Menopausal\n\uf06f OCP \uf06f HRT \n \nCOLPOSCOPIC IMPRESSION \n\uf06f NEGATIVE \uf06f HPV / LSIL \uf06f HSIL\n* Each specimen container must be labelled with the patient's full first and last name and the exact specimen site.\n \n\uf06f BIOPSY \uf0a1 Punch \uf0a1 Cone \uf0a1 Leep LAB USE ONLY \nGROSS DESCRIPTION: \nBiopsy consists of fragments measuring: mm greatest Location: _____ o'clock \uf06f Cervix \uf06f Vagina \uf06f Vulva \uf06f Other: __________ \n\uf06f BIOPSY \uf0a1 Punch \uf0a1 Cone LAB USE ONLY \nGROSS DESCRIPTION: \nBiopsy consists of fragments measuring: mm greatest Location: _____ o'clock \uf06f Cervix \uf06f Vagina \uf06f Vulva \uf06f Other: __________ \n\uf06f BIOPSY \uf0a1 Punch \uf0a1 Cone LAB USE ONLY \nGROSS DESCRIPTION: \nBiopsy consists of fragments measuring: mm greatest Location: _____ o'clock \uf06f Cervix \uf06f Vagina \uf06f Vulva \uf06f Other: __________ \n\uf06f BIOPSY \uf0a1 Punch \uf0a1 Cone LAB USE ONLY \nGROSS DESCRIPTION: \nBiopsy consists of fragments measuring: mm greatest Location: _____ o'clock \uf06f Cervix \uf06f Vagina \uf06f Vulva \uf06f Other: __________ \n\uf06f CURETTINGS \uf06f BIOPSY LAB USE ONLY \nGROSS DESCRIPTION: \n \nBiopsy consists of fragments measuring: mm greatest \uf06f Endocervix \uf06f Endometrium\n\uf06f CURETTINGS \uf06f BIOPSY LAB USE ONLY \nGROSS DESCRIPTION: \nBiopsy consists of fragments measuring: mm greatest \uf06f Endocervix \uf06f Endometrium\n578788878\n1998-12-11\nKash\nDiv\n\u25a0\n52 Castlefall Way NE\nCaglary\nChoose Province\nT3J1M7\nMequanent\nTed\n1"}...
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{"status": "completed", "conte {"status": "completed", "content": "Scanning Label or Accession # (lab only)\nProvider(s)\n Patient\nCollection\nPHN\nExpiry: ________\nDate of Birth (dd-Mon-yyyy)\nLegal Last Name Legal First Name Middle Name\nAlternate Identifier Preferred Name o Male o Female\no Non-binary o Prefer not to disclose\nPhone\nAddress City/Town Prov Postal Code\nAuthorizing Provider Name (last, first, middle) Copy to Name (last, first, middle) Copy to Name (last, first, middle)\nAddress Phone Address Address\nCC Provider ID CC Submitter ID Legacy ID Phone Phone\nClinic Name Clinic Name Clinic Name\nDate (dd-Mon-yyyy) Time (24 hr) Location Collector ID\nHematology Specialty Requisition\nClient Response Centre 780-407-7484\nCH-0312(Rev2022-07)\nHIT\no Heparin-induced thrombocytopenia\nPrevious heparin exposure (past 3 months)?\no No o Yes \u2013 if Yes, indicate UNFH or\nspecific LMWH brand\n___\n__________________________\nStart Date _________\n___________\nStop Date ____________________\nThrombosis while on heparin? o \nNo o Yes\n4T score _____________________________\nSpecial Hematology\no Glucose-6-Phosphate Dehydrogenase Panel\no Fetomaternal Blood Quantification\nHemoglobinopathy / Malaria Investigation\no Hemoglobin F and S Quantitation\no Hemoglobinopathy investigation\n Ethnic origin ____\n______________\no Malaria\n Travel \nhistory _________________\nBlood Smear & Bone Marrow Aspirate\nExamination Required \no Smear for Consult Panel\no\nBone Marrow Exam Panel: aspiration/biopsy\n(pre-book at 780-407-7484 for UAH patients or\nthrough laboratory at other hospitals)\nOrder any required Microbiology testing on their separate \nrequisition\nComplete During Procedure\nSite o Left Iliac Crest o\n Right Iliac Crest\no Bilateral Iliac Crests\no Sternum\no Other (specify) _______________________\nPerformed by\n (name) _______________________\nTrephine biopsy length ________________________\nCytogenetics\no Karyotype\no FISH (specify) ___________________________\no Other (specify) ___________________________\nFlow Cytometry \u2013 Immunophenotyping\no Leukemia/Lymphoma Immunophenotyping\nOne or more Indication(s) below MUST be selected:\no Lymphoma / Lymphoproliferative \ndisorder\no Acute Leukemia\no Minimal Residual Disease\no Plasma Cell Neoplasia\no Pancytopenia (Bone Marrow ONLY)\no PNH panel\no B Cell Enumeration\no T-Cell Subsets CD3/CD4/CD8 Only\no Hereditary Spherocytosis\no Hereditary Spherocytosis with Osmotic Fragility\n(Pre-book at 780-407-7484)\nOther T\nests\nSPECIMEN\no Blood o Bone Marrow o Other (specify) ____________________________________________________________\nHIST\nORY\nHistory and object of examination:\nPertinent drug history:\no on Coumadin o on Heparin\no on other anticoagulants (specify)\n _______________________\no on G-CSF\nOther ____________________________\n____________________\nPhysical findings:\nSplenomegaly \u00a3 No \u00a3 \nYes _________________________________\nHepatomegaly \u00a3 No \u00a3 \nYes ________________________________\nLymphadenopathy \u00a3 \nNo \u00a3 \nYes ________________________________\nPregnant \u00a3 \nNo \u00a3 \nYes ________________________________\nOther _____________________________________________________\nRecent Transfusions _____________________________________________\n578788878\n1998-12-11\nKash\nDiv\n52 Castlefall Way NE\nCaglary\nChoose Province\nT3J1M7\nMequanent\nTed\n1"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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{"status": "completed", "conte {"status": "completed", "content": "To cancel or rebook your appointment, please call Central Booking: Mon-Fri: 8AM-7PM, Sat: 9AM-4PM, Sun: Closed\nBreast Procedure Requisition\nCentral Booking\n780-669-2222\nToll Free\n1-866-771-9446\nName: Appointment Details:\nAddress: Date:\nInsurance: W.C.B. ( ) Other: Location:\nToll Free Fax\n1-855-930-1593\nFax\n780-930-1593\nPhone: FemaleMale Non-Binary Time:\nPhysician's Stamp\n& Practice ID\nURGENT FAX REPORT (until 4 pm, M-F)\nReferring Physician's Information\nAddress:\nName:\nDate:\nSignature:\nPhone: Fax: \nCopy To:\nPhone:\nFax:\nName:\nPregnant? Yes No LMP:\nRelevant History, Physical Findings, and Provisional Diagnosis\nDiagnostic Mammo\nL R Bilat\nBreast Ultrasound\nL R Bilat\nAxilla Ultrasound\nL R Bilat\nAxilla Biopsy: L R\nWire Localization (please specify if bracketing is requested)\nSite 1: L R\nSite 2: L R\nSite 3: L R\nFine Needle Aspiration CytopathologySend for: Microbiology\nSite 1: L R\nSite 2: L R\nSite 3: L R\nSentinel Node Injection: L R\nBreast Biopsy\nVAB\nVAB (Vacuum Assisted Biopsy) - Lendrum only\nVAB\nVAB\nSite 1: L R\nSite 2: L R\nSite 3: L R\n(Meadowlark and Sherwood Park only)\nIncomplete requisitions \nwill be returned\nPLEASE\nNOTE:\nDOB: \nMM/DD/YYYY\nREV 01/2022\n1998-12-11\n4036481926\n4036481926\n1\n1 ** ALL EXAMINATIONS ** \nFREE PARKING AT ALL SITES\nRemember to bring the Imaging Requisition plus your Health Care Card and photo ID. \nIf you are unable to keep your appointment, and need to reschedule, please phone the clinic directly. (There is no facility to look after small \nchildren). The following examinations are by appointment only. When making an appointment, please notify if patient is diabetic or pregnant.\nPlease phone 780-669-2222 to\nschedule your appointment\nFREE PARKING AT ALL SITES\nLendrum Women's Imaging\n10381 - 51 Avenue T6H 0K4 \nPh: 780-434-9171 | F: 780-436-5211\nMeadowlark\n200 Meadowlark Shopping Centre\n156 Street - 89 Avenue T5R 5W9 \nPh: 780-489-8430 | F: 780-481-6630\nSherwood Park\n136 Athabascan Avenue T8A 4E3 \nPh: 780-464-1515 | F: 780-464-1216\nLOCATIONS & SERVICES\nMammography\n- It is suggested that you wear a two-piece outfit so you may change into your robe more easily.\n- Do not use deodorant, talcum (body powder), or lotion/oil the day of your exam.\n- If you have significant premenstrual breast tenderness, you may reschedule your appointment.\n- We recommend avoiding caffeine intake for 2 days prior to your mammogram to decrease discomfort during your exam.\nBreast Biopsy\n- It is suggested that you wear a two-piece outfit so you may change into your robe more easily.\n- Do not use deodorant, talcum (body powder), or lotion/oil the day of your procedure.\n- We recommended that you eat breakfast or lunch before coming for your procedure.\n- Expect to be at our clinic for approximately 60-90 minutes.\n- Notify the clinic of any drug or latex allergies before your procedure.\n- No heavy lifting or strenuous activity for 48 hours after your procedure.\n- Vacuum assisted biopsy only: If you are on blood thinners, we recommend that you check with your family\nphysician about discontinuing your blood thinners prior to your procedure.\nServices\n\u2022 Breast wire localizations\n\u2022 Breast and axilla ultrasound guided biopsies\n\u2022 Fine needle breast and axilla aspirations\n\u2022 Sentinel node injections\nServices\nServices\n\u2022 Sentinel node injections\nPATIENT PREPARATION INSTRUCTIONS:\nGateway Blvd.\n99 St\nCalgary Trail NW\n106 St\n51 Ave NW\nWhitemud Dr NWWhitemud Dr NW\nBroadmoor Blvd.Broadmoor Blvd.\nChippewa Rd.\nAnthony Henday Dr.\nBaseline Road\nMain Blvd.Blackfoot Rd.\n\u2022 Breast wire localizations\n\u2022 Breast and axilla ultrasound guided biopsies\n\u2022 Stereotactic guided biopsies\n\u2022 Vacuum assisted biopsies\n\u2022 Fine needle breast and axilla aspirations"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \n65\nKash jf\nDiv af\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n1998-12-11\n578788878\nWhite\n52 Castlefall Way NE\nCaglary\nT3J1M7\nCalgary\n4032354147\nChoose Province\nDavid"}...
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