Prescription and Request for BPAP Funding for Adults with 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Client's name, personal health number, and date of birth as they appear on their Alberta Personal Health Card. Include the Client's address and contact number.
3. Input the details of the Respiratory Assessor, including their name, designation, facility, and contact information. Ensure accuracy as this information is crucial.
4. If applicable, provide the hospital name, unit number, and tentative discharge date for Clients currently hospitalized.
5. Specify the current diagnosis based on whether the Client has a rapidly progressive or stable/slowly progressive condition. Follow the guidelines provided in the form.
6. For Clients with rapidly progressive conditions, ensure they meet one of the specified medical requirements and attach necessary documentation.
7. Fill in prescribed BPAP settings including mode and specific parameters like IPAP and EPAP values.
8. Indicate the preferred BPAP Specialty Supplier based on Client needs.
9. If oxygen is required alongside BPAP, confirm that both suppliers are aligned whenever possible.
10. Complete the prescribing physician's details including name, phone number, fax number, and signature. Ensure it is signed by a certified pulmonologist.
11. Add any additional comments if necessary before finalizing your submission.

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