ltc_phn_07-06 by fanzhongqing

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									     PHNs IN LONG-TERM CARE FACILITES - PHARMACARE SHORT TERM ANALYSIS

        All data collected is confidential and will be used for healthcare policy analysis and research purposes only.

For Month of:
Pharmacy Name:
Pharmacy Code:
Maximum # of Beds Allowed
# of Beds Claimed

INSTRUCTIONS:
Please submit the data specified in this document on this form.
Submissions in MS Word are acceptable if you do not have MS Excel.
In the space provided below, please enter complete information for all patients served by your pharmacy during the
month you have specified above. Rows can be added as needed.

MEDICATION INSURER CODES:
PharmaCare = PC
Other Insurer = OI                                     For example, Veterans Affairs, RCMP, Blue Cross, etc.
Patient Pay = PP
No Medication = NM


                LTC Facility Name                              Personal Health Number                     Insurer Code




  Sheet1                                Province of British Columbia Confidential                                        Page 1
         LTC Facility Name                     Personal Health Number    Insurer Code




Sheet1                       Province of British Columbia Confidential              Page 2
         LTC Facility Name                     Personal Health Number    Insurer Code




Sheet1                       Province of British Columbia Confidential              Page 3
         LTC Facility Name                     Personal Health Number    Insurer Code




Sheet1                       Province of British Columbia Confidential              Page 4
         LTC Facility Name                     Personal Health Number    Insurer Code




Sheet1                       Province of British Columbia Confidential              Page 5
         LTC Facility Name                     Personal Health Number    Insurer Code




Sheet1                       Province of British Columbia Confidential              Page 6
         LTC Facility Name                     Personal Health Number    Insurer Code




Sheet1                       Province of British Columbia Confidential              Page 7
         LTC Facility Name                     Personal Health Number    Insurer Code




Sheet1                       Province of British Columbia Confidential              Page 8
         LTC Facility Name                     Personal Health Number    Insurer Code




Sheet1                       Province of British Columbia Confidential              Page 9
         LTC Facility Name                     Personal Health Number    Insurer Code




Sheet1                       Province of British Columbia Confidential             Page 10
         LTC Facility Name                     Personal Health Number    Insurer Code




Sheet1                       Province of British Columbia Confidential             Page 11
         LTC Facility Name                     Personal Health Number    Insurer Code




Sheet1                       Province of British Columbia Confidential             Page 12
         LTC Facility Name                     Personal Health Number    Insurer Code




Sheet1                       Province of British Columbia Confidential             Page 13
        PHNs IN LONG-TERM CARE FACILITES - PHARMACARE SHORT TERM ANALYSIS

        For Month of:
        Pharmacy Name:
        Pharmacy Code:
        Maximum # of Beds Allowed
        # of Beds Claimed

        Notes: provided is confidential and
        All data
        Please submit healthcare policy
        will be used forthe data specified in
        this document on this form.
        Please enter complete information
        for patients served by the pharmacy
        Indicate the medication insurer
        the following codes:
        PharmaCa
        re       PC
        Other
        Insurers    OI
        Private
        Pay         PP
        No
        Medicatio
        n         NM



                             Medicatio
                             n Insurer
                   Personal
                              (Please
                    Health
Name Long Term Care Facility
                               follow
                    Number
                             Standard
                              Format)

								
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