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Sunday, August 28, 2016
Publications Centre




Communicable Disease
Product List
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A
  Application for Pharmacy Payment Vendor Code - (for Pharmacy Use Only)
Form filled by pharmacists to arrange payment for pharmacy claims through Saskatchewan Finanace.
  Aricept/Exelon/Reminyl Exception Drug Status Application - (for Physician Use Only)
Application form used by physicians to request drug coverage for Aricept or Exelon on behalf of their patients.
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D
  Direct Deposit Payment Request Form - (for Medical Services use only)
Form used by Health Providers registered with Medical Services Branch to arrange direct payment.
  Direct Deposit Payment Request Form - (for Pharmacy Use Only)
Form used by pharmacists to arrange direct payment for pharmacy claims.
  Drug Plan - Cancelled Claims Advisory - (for Pharmacy Use Only)
Allows pharmacies to cancel claims already adjudicated electronically but cannot be reversed electronically.
  Drug Plan - Certificate Authorization Form
Pharmacists must complete form to receive certificates for security purposes. The certificates ensure that only pharmacies access the drug plan data base.
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E
  Exception Drug Status Application for Ankylosing Spondylitis Drugs - (for Rheumatologist Use Only)
Application form used by Rheumatologists to request Exception drug status coverge for drugs used to treat Ankylosing Spondylitis on behalf of their patients/ clients.
  Exception Drug Status Request Form - (for Pharmacy or Physician Use Only)
Application form used by physicians and pharmacists to request Exception drug status coverage on behalf of their patients/ clients.
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H
  Health Provider Questionnaire (Medical Services)
The Health Provider Questionnaire provides pertinent information for the Medical Services Health Provider registry, it provides information about Health Providers who are registering with their licensing body. ie: the College of Physicians and Surgeons of Saskatchewan, the College of Dental Surgeons of Saskatchewan, the Saskatchewan of Optometrists, and Chiropractors' Association of Saskatchewan.
  Health Services Card Application
Used by new and returning residents to apply for provincial health coverage. Form is to be completed immediately following the establishing of Saskatchewan residency.
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I
  Institutional Supportive Care Income-Tested Resident Charge -Side A- CRA Consent Form
This consent form authorizes Canada Revenue Agency (CRA) to supply total income each year to Drug Plan & Extended Benefits in order to calculate the income-tested resident charge.
  Institutional Supportive Care Income-Tested Resident Charge -Side B- Annual Consent Form
This consent form is used to request income information each year in order to calculate the income-tested resident charge.
  Institutional Supportive Care Long Term Care Optional Designation for Determining Resident Charge
Married residents may choose to complete this form to calculate the long-term care resident charge using the resident's income only.
  Institutional Supportive Care Long Term Care Resident Nomination and Consent Form
To provide information for the designated representative of a resident in long term care.
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L
  Laboratory Licensing – Application/Renewal for a Licence to Operate a Medical Laboratory
Application/renewal form for a licence to operate a medical laboratory.
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M
  Medical Statement Request Application
Medical Statements are listings of physician services, the date of service, and the community where the service was provided. Completion of this application provides consent to Medical Services to produce this information.
  MS Drugs Exception Status Application - (for Physician Use Only)
Application form used by physicians to request coverage (on behalf of their patients) for drugs used in treatment of multiple sclerosis, specifically Betaseron/Copaxone/Rebif/Avonex-form is submitted to the MS Drug Advisory Panel for review.
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N
  Narcotics and Controlled Drugs
For use by staff in long term care facilities to track drug usage.
  New Clinic Request Application (for Health Providers use only)
Form used by Health Providers registered with Medical Services Branch to open a new clinic within Saskatchewan and/or additions to an existing clinic.
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P
  Pharmacy Claim - In Province - (for Pharmacy Use Only)
Manual billing of prescription claims from community pharmacies located in Saskatchewan. These pharmacies submit the claim for payment if the claim is not electronically adjudicated on the Drug Plan network. Some reasons may be because of quantity restrictions or a change in coverage.
  Pharmacy Claim - Out of Province - (for Pharmacy Use Only)
Manual billing of prescription claims from out patient hospital pharmacies located outside of Saskatchewan. These pharmacies submit the claim so patients receiving treatment outside of the province don't pay costs or pay as they would if in Saskatchewan
  Physician Profile Request Form
The Medical Services Branch prepares practitioner profiles on a fiscal year basis. The fiscal year begins April 1 and ends March 31 of the following year.
  Physician Request for Income Statement
The Medical Services Branch prepares requests for Income Statements based on information received from a Saskatchewan Physician who has received Fee-For-Service Income from the Ministry of Health.
  Practitioner Change Request Form
Form used by Health Providers registered with Medical Services Branch to notify of name changes, clinic address changes, and or correspondence changes listed in the Practitioner Registry.
  Professional Corporation Information
Professional corporation information
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R
  Request for Palliative Care Coverage - (for Physician Use Only)
Application form completed by physicians on behalf of their patients to request Palliative Care drug coverage under the Drug Plan.
  Request for Review of Claim Assessment
Allows the doctor to request a review of a paid claim which he believes should be paid at a higher or lower rate of payment.
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S
  Seniors' Drug Plan - Form A - CRA Application/Consent One-Time Application
To apply for the Seniors' Drug Plan program, each eligible senior must complete and sign an application and consent form. By using Form A, you are giving the Drug Plan and Extended Benefits Branch permission to update your coverage annually.
  Seniors' Drug Plan - Form B - Annual Application
To apply for the Seniors' Drug Plan, use Form A for a one-time application or this form which is to be completed and submitted with your income information each year.
  Special Support Program - Drug Plan - Side A - CRA Application/Consent Form
This form is used to request income information for assessment of eligibility for those with high drug costs in relation to income. This one-time form authorizes the Drug Plan to obtain your income tax information from Canada Revenue Agency (CRA), so you do not need to apply every year. If you decide you do not want the automatic renewal process, the Annual Application Form (SIDE B) allows you to complete a renewal form and submit it with your income information each year.
  Special Support Program - Drug Plan - Side B - Annual Application
This form is used to request income information for assessment of eligibility for those with high drug costs in relation to income. You must complete this form and submit it with your income information each year. If you prefer to submit a one-time form that authorizes the Drug Plan to obtain your income tax information from Canada Revenue Agency (CRA), please use the CRA Application/Consent Form SIDE A).
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T
  Therapeutic Nutritional Products
This referral form is used by registered dieticians. The Therapeutic Nutritional Products Program assists with the cost of specialized nutritional products for persons with complex medical conditions who rely on such products as their primary source of nutrition.
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W
  Water Analysis Requisition - Provincial Laboratory (for Municipal-Saskatchewan Environment only)
Used to submit water samples from Saskatchewan Environment regulated sites.
  Water Analysis Requisition - Provincial Laboratory (for Private Users Only)
Used by private individuals to submit drinking water samples for analysis at the Provincial Laboratory.
  Water Analysis Requisition - Provincial Laboratory (for Public Health only)
Used to submit water samples from Public Health regulated sites for analysis at the Provincial Laboratory.
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