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{"status": "completed", "conte {"status": "completed", "content": "Please fax recent lab\n invesgaons, including Lipids,\nECG and Medica on List.\n \nDate:_________________________________________\nPhysician name:_________________________________\nPhysician address:_______________________________\nPhysician number:_______________________________\nPhysician signature:______________________________\nConsidered a valid prescripon when signed by a physician\nCopies to:_____________________________________ _\n250, 8500 Blackfoot Trail SE\nCalgary, AB T1Y 0B4\nT 403.879.7911\nF 403.879.7899\n201, 3151 27thStreet NE \nCalgary, AB T1Y 0B4\nT 403.235.4109 \nF 403.235.4147\nInternal Medicine\nEndocrinology\n\u2751Geriatric Medicine\nPaent Informaon Referring Physician\nConsultaon Requested:\n\u2751Cardiology\n\u2751\n\u2751\nMD, FCCP Internal Medicine\nMD, FACP Internal Medicine\nMD, FRCPC Cardiologist\nDr. Ravi Varshney\nDr. Lovpreet Mangat\nMD, FRCPC Internal Medicine\nDr. Faisal Hasan\nMD, MRCP Endocrinologist\n\u2751\n\u2751\n\u2751\nDr. Anmol Kapoor\nMD FRCPC Cardiologist\nDr. Alvin Villanueva\nDr. Ali Debek\n\u2751\n\u2751\n\u2751\nConsult\nUrgent (within 2 weeks) Semi-Urgent (more than 2 weeks) Phone Consult \u2013 Call 403.235.4109 to request\u2751 \u2751\u2751 \u2751ASAP\nPaent Like hood of CAD:\n \n(Plaque presence, caro d inmal medial thickness)\n) \nStroke / TIA\nFollow-up of known carod stenosis\nfollow-up\nPCOS\nHypo / Hyper Thyroid\nHirsusm/Amenorrhoea\nAdrenal Disorder\nAbnormal ECG\nPost PCI\nAbnormal Treadmill Stress Test\nMurmur\nShortness of breath\nHypertension / Le ventricular Hypertrophy\nPulmonary HypertensionIntermediate High\nCardiac Diagnosc Examinaon\nMyocardial Perfusion Imaging\n(MPI\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nExercise MPI\u2751\n\u2751Pharmacological MPI\nDoes Your Paent Have:\nMedicaon:\nCAD / CHF\nF/U Known Stable CAD\nFunconal Significance Coronary Stenosis\nChest Pain\nPalpitaons / Arrhythmias \n(suspected/known history of arrhythmia)\nEdema / PND / Orthopnea\nCardiovascular risk assessment\nSyncope / Presyncope / Vergo / Dizziness\nCarod Bruit\nPost-surgical angiographic intervenon \nLow Testosterone\nYoung Type 2 Diabetes\nPituitary Disorder\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n Please Check all that apply:Indicaons:\n(Includes Cardiology Consult)\n\u2751\n\u2751 Diabetes Type 2/Complex\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nBubble Echocardiogram\n(Includes Cardiology consult)\nEchocardiogram \nCarod ultrasound\nExercise Stress Test\n(Includes Cardiology Consult)\n24 Hour Holter Monitor\n\u275148 Hour Holter Monitor\n5 day Holter Monitor\n\u2751ECG \u2013 Electrocardiogram\n24 hour BP Monitor\n\u2751ABI (Ankle Brachial Index)\n\u2751\nLow\n.\nwww.advancedcardiology.caPlease fax completed form - we will call the paent to book\nClinical Notes:\n \nHeight___cm/in Weight___lb/kg \nYes No\nNo\nNo\nNo\nNo\nYes\nYes\nYes\nYes\nDiabetes\nAsthma\nPacemaker\nICD\nCABG\nUrgency\nReferral\n\u2751Stress Echocardiogram\n(Includes Cardiology Consult)\nMALE FEMALE\n\u25a0\n\u25a0\nSulaiman Alnasser\n3151 27 St NE #201, Calgary, AB T1Y 7J8, Alberta\n(403) 235-4109\nDiv Kash\n666777888\n52 Castlefall Way NE, Caglary, T3J1M7, AB\n15879987876\n\u25a0\n12-Dec-2025\n24-Oct-2025"}...
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{"status": "completed", "conte {"status": "completed", "content": "Please fax recent lab\n invesgaons, including Lipids,\nECG and Medica on List.\n \nDate:_________________________________________\nPhysician name:_________________________________\nPhysician address:_______________________________\nPhysician number:_______________________________\nPhysician signature:______________________________\nConsidered a valid prescripon when signed by a physician\nCopies to:_____________________________________ _\n250, 8500 Blackfoot Trail SE\nCalgary, AB T1Y 0B4\nT 403.879.7911\nF 403.879.7899\n201, 3151 27thStreet NE \nCalgary, AB T1Y 0B4\nT 403.235.4109 \nF 403.235.4147\nInternal Medicine\nEndocrinology\n\u2751Geriatric Medicine\nPaent Informaon Referring Physician\nConsultaon Requested:\n\u2751Cardiology\n\u2751\n\u2751\nMD, FCCP Internal Medicine\nMD, FACP Internal Medicine\nMD, FRCPC Cardiologist\nDr. Ravi Varshney\nDr. Lovpreet Mangat\nMD, FRCPC Internal Medicine\nDr. Faisal Hasan\nMD, MRCP Endocrinologist\n\u2751\n\u2751\n\u2751\nDr. Anmol Kapoor\nMD FRCPC Cardiologist\nDr. Alvin Villanueva\nDr. Ali Debek\n\u2751\n\u2751\n\u2751\nConsult\nUrgent (within 2 weeks) Semi-Urgent (more than 2 weeks) Phone Consult \u2013 Call 403.235.4109 to request\u2751 \u2751\u2751 \u2751ASAP\nPaent Like hood of CAD:\n \n(Plaque presence, caro d inmal medial thickness)\n) \nStroke / TIA\nFollow-up of known carod stenosis\nfollow-up\nPCOS\nHypo / Hyper Thyroid\nHirsusm/Amenorrhoea\nAdrenal Disorder\nAbnormal ECG\nPost PCI\nAbnormal Treadmill Stress Test\nMurmur\nShortness of breath\nHypertension / Le ventricular Hypertrophy\nPulmonary HypertensionIntermediate High\nCardiac Diagnosc Examinaon\nMyocardial Perfusion Imaging\n(MPI\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nExercise MPI\u2751\n\u2751Pharmacological MPI\nDoes Your Paent Have:\nMedicaon:\nCAD / CHF\nF/U Known Stable CAD\nFunconal Significance Coronary Stenosis\nChest Pain\nPalpitaons / Arrhythmias \n(suspected/known history of arrhythmia)\nEdema / PND / Orthopnea\nCardiovascular risk assessment\nSyncope / Presyncope / Vergo / Dizziness\nCarod Bruit\nPost-surgical angiographic intervenon \nLow Testosterone\nYoung Type 2 Diabetes\nPituitary Disorder\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n Please Check all that apply:Indicaons:\n(Includes Cardiology Consult)\n\u2751\n\u2751 Diabetes Type 2/Complex\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nBubble Echocardiogram\n(Includes Cardiology consult)\nEchocardiogram \nCarod ultrasound\nExercise Stress Test\n(Includes Cardiology Consult)\n24 Hour Holter Monitor\n\u275148 Hour Holter Monitor\n5 day Holter Monitor\n\u2751ECG \u2013 Electrocardiogram\n24 hour BP Monitor\n\u2751ABI (Ankle Brachial Index)\n\u2751\nLow\n.\nwww.advancedcardiology.caPlease fax completed form - we will call the paent to book\nClinical Notes:\n \nHeight___cm/in Weight___lb/kg \nYes No\nNo\nNo\nNo\nNo\nYes\nYes\nYes\nYes\nDiabetes\nAsthma\nPacemaker\nICD\nCABG\nUrgency\nReferral\n\u2751Stress Echocardiogram\n(Includes Cardiology Consult)\nMALE FEMALE\nLovpreet Mangat\n3151 27 St NE #201, Calgary, T1Y7J8, AB\n(403) 235-4109\nDiv Kash\n666777888\n52 Castlefall Way NE, Caglary, T3J1M7, AB\n15879987876\n\u25a0\n12-Dec-2025\n14-Oct-2025"}...
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{"status": "completed", "conte {"status": "completed", "content": "Logo\nAdvanced Cardiology Consultants & Diagnostic Inc\n#250 8500 Blackfoot Trail SE\nCalgary, AB, T2J7E1\nTel: 403-879-7911 | Fax 403-879-7899\nNUCLEAR MYOCARDIAL PERFUSION IMAGING STRESS STUDY\n9/24/2025 Chart No: A43819\nRef. Dr.: Family Dr.:\nRE: Div Kash Supervising MD:\nFindings\nNormal myocardial perfusion. No fixed or reversible perfusion abnormalities.\nImpression\nNormal systolic function.\nInformation contained in this communication may be confidential..."}...
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{"status": "completed", "conte {"status": "completed", "content": "Advanced Cardiology Consultants & Diagnostic Inc\n#250 8500 Blackfoot Trail SE\nCalgary, AB, T2J7E1\nTel: 403-879-7911 | Fax 403-879-7899\nNUCLEAR MYOCARDIAL PERFUSION IMAGING STRESS STUDY\n1/21/2026 Chart No: A4381909\nRef. Dr.: Family Dr.:\nRE: Div Kash Supervising\nMD:\nPHN: 578788878 Technologist:\nDOB: 12/11/1998 Clinical History:Chest pain\nECG Information Resting ECG:\nundefined Stress Test Information\nInterpretation by: undefined Stress Interpretation ECG:\nProtocol: ECG Gating: No Dipyridamole Dose: undefined\nReason of Termination:\nMedication During Test: Aminophylline undefined mg,\nStage Heart Rate (bpm) Blood Pressure\nPre-Pharmacological Stress\n2 Min\n4 Min\n6 Min\n8 Min\nRecovery\nMPI Technique:\nundefined Mbq Tc-Tetrofosmin administered at rest.\nundefined Mbq Tc-Tetrofosmin administered post-pharmacological stress.\n(0.56 mg/kg infusion over 4 minutes, injection at 7 minutes)\nImage quality: undefined\nFindings:\nNormal myocardial perfusion. No fixed or reversible perfusion abnormalities.\nImpression:\nNormal systolic function.\nMPI Interpreting Physician: undefined Report Date: 1/21/2026\nPaPrinted by Super Admin, Jan 21, 2026 at 08:10:24 a.m."}...
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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 abcd\nDiv ctg\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": "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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{"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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{"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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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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1772237214
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/home/sid/xevyo/open-webui-dev/backend/data/upload /home/sid/xevyo/open-webui-dev/backend/data/uploads/77eab211-ecbc-4018-83f8-e20e1e57d72b_labs-9f904d45-7f24-4063-b213-3c288cf67214.pdf...
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b0e1a6cb-2268-478b-8d1a-962d2aeb99b8
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labs-79dbc7c8-7c02-417a-93de-cf9db167d60e.pdf
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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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labs-18c5dd82-c58b-4509-8934-2a4a373487b6.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-a30cff88-01f1-4cda-83f5-ef468c556402.pdf
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{"name": "labs-a30cff88-01f1-4cda-83f5 {"name": "labs-a30cff88-01f1-4cda-83f5-ef468c556402.pdf", "content_type": "application/octet-stream", "size": 640549, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-24774d4a-4cd2-42fb-824e-668823994970"}...
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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-83f3117b-3606-4c2f-97e3-1d059ea63555.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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labs-5d8a6246-f3e7-4d3f-9bca-8430472f593f.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\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": "Div Kash (A4381909) DOB: Dec 11, 1998 Age: 27\nDate: Jan 21, 2026 Chart Note:\nBP\nHeart Rate (bpm)\nHeight (cm) 167\nWeight (kg) 120\nBMI (kg/m^2) 76.4\nComplaint 4343\nPast Medical History: MOA 43434\nCardiac Risk Factor: MOA 4343\nPhysical Examination 364yht\nSurgical History hgfhgfh\nECG hgfhg\nAllergies to Medication hgf\nPlan: hgfutyhnhf\nFollow-up: ngnhfnh\nPrinted by Super Admin, 2026-01-21, 9:20:11 a.m. \u2014 Page: 1"}...
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{"name": "labs-2f83ce40-6dea-4829-836c {"name": "labs-2f83ce40-6dea-4829-836c-54d23b3cd826.pdf", "content_type": "application/octet-stream", "size": 640563, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-08bf338f-2a95-48ff-8f52-12fc4f77e1be"}...
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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": "Div Kash (A4381909) DOB: 12/11/1998 Age: 27\nDate: Jan 21, 2026 Chart Note:\nAddress and phone given to the patient\nPrinted by Super Admin, 2026 at Jan 21, 2026 10:37:05 AM Page: 1"}...
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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) \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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{"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\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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{"name": "chart-1768993359233-plain.pd {"name": "chart-1768993359233-plain.pdf", "content_type": "application/octet-stream", "size": 34567, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-27ed9521-d329-4d09-a630-5f802aef3cf9"}...
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{"status": "completed", "conte {"status": "completed", "content": "Div Kash (A4381909) DOB: 12/11/1998 Age: 27\nDate: Jan 21, 2026 Chart Note:\nAddress and phone given to the patient\nBooked appointment for Pt.\nPrinted by Super Admin, 2026 at Jan 21, 2026 11:02:39 AM Page: 1"}...
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labs-51f0d871-77cd-4edc-954b-f6e8c7a52d64.pdf
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{"name": "labs-51f0d871-77cd-4edc-954b {"name": "labs-51f0d871-77cd-4edc-954b-f6e8c7a52d64.pdf", "content_type": "application/octet-stream", "size": 314633, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-47a99f56-2031-421e-9296-8535d94d89a1"}...
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{"status": "completed", "conte {"status": "completed", "content": "For more information visit www.myhealth.alberta.ca\nWho can I call with questions?\nHealth Link Alberta 1.866.408.5465 These recommendations are aligned with Choosing Wisely Canada.\nWho needs \nvitamin D testing?\n\u2022\t While\tthere\tis\tgood\tscientific\t\nevidence that all Albertans need \nmore vitamin D through foods and \nsupplements, there is no good \nevidence to support regular blood \ntesting to determine vitamin D \nlevels for most of us, except in \nmedically necessary cases.\n\u2022\t Medically\tnecessary\tcases\t\ninclude: those with osteoporosis \nor other bone-thinning diseases, \nmalabsorption syndromes, \nrenal disease, rickets, or patients \ntaking drugs that affect vitamin D \nabsorption.\nWhy do you \nneed vitamin D?\n\u2022\t Vitamin\tD\thelps\tour\tbodies\tbuild\t\nstrong, healthy bones and teeth. It \nmay also lower your risk for heart \ndisease, cancer, diabetes, high \nblood pressure and other diseases.\n\u2022\t Your\tbody\tneeds\tVitamin\tD\tto\t\nabsorb calcium, and without \nenough calcium, your muscles \ncan cramp, hurt, or feel weak. \nYou\tmay\thave\tlong-term\tmuscle\t\naches and pains. If you don't get \nenough vitamin D throughout your \nlife, you are more likely to have \nthin and brittle bones (known as \nosteoporosis) in your later years.\nHow do you get \nenough vitamin D?\n\u2022\t Our\tskin\tmakes\tsome\tVitamin\tD\t\nfrom sunlight; but because of our \nlong winters, most Canadians \nmake little or no vitamin D \nbetween\tOctober\tand\tMarch\tand\t\nneed to get it from other sources. \n\u2022\t As\ta\tresult,\ta\tvery\timportant\tway\t\nof getting enough vitamin D is \nthrough the food we eat. This \nincludes foods like egg yolks, liver, \nand\tfish\tsuch\tas\tchar,\therring,\t\nmackerel, salmon, sardine and \ntrout.\tEating\tfish\ttwice\ta\tweek\t\nthrough healthier cooking methods \nsuch as poaching, baking, or \nbarbequing is a great way to \nsupplement your vitamin D intake. \nvitamin D can also be found in 2-3 \nservings\tof\tmilk\tand/or\tfortified\tsoy\t\nor rice beverage each day. \n\u2022\t In\taddition\tto\tVitamin\tD\tfrom\t\nfoods, at minimum most children \nand adults require a 400 IU \nsupplement daily, but no more \nthan 1,000 IU. Adults over the age \nof 70 require at minimum an 800 \nIU supplement daily, but no more \nthan 2,000 IU. For most people, \nthe best supplement is vitamin D3. \nVitamin D \nand your \nhealth"}...
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{"name": "chart-1768978821802-plain.pd {"name": "chart-1768978821802-plain.pdf", "content_type": "application/octet-stream", "size": 35598, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-31e09a8c-1939-4f49-ad3f-2d6eaa3ba77b"}...
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{"status": "completed", "conte {"status": "completed", "content": "Div Kash (A4381909) DOB: 12/11/1998 Age: 27\nDate: Jan 21, 2026 Chart Note:\nAddress and phone given to the patient\nConfirmed appointment date & time with Pt. All instructions given...\nPrinted by Super Admin, 2026 at Jan 21, 2026 07:00:21 AM Page: 1"}...
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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": "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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{"name": "labs-cf23d619-3f55-4494-af69 {"name": "labs-cf23d619-3f55-4494-af69-e35149dd8456.pdf", "content_type": "application/octet-stream", "size": 647630, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-c2ad4e74-d6c9-4930-9332-c67979e9f7a5"}...
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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\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": "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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