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New/Replacement Clinical Product and Equipment Request Form

Instructions for completion:

  1. Form is to be used for any new or replacement clinical supply item or minor equipment request.
  2. This form is NOT intended for major capital equipment requests, but IS to be used for equipment-related supply items.
  3. In order for requests to be considered, please complete entire form. Form must include the name and contact number of a knowledgeable and available clinical contact.
  4. Forward additional information required to Corporate Purchasing via fax at 410-550-3331, 3332.

Please note: Fields marked with << are required.

CLINICAL CONTACT FOR QUESTIONS
If code is not listed above, please provide it
PRODUCT INFORMATION: Please forward manufacturer's specifications, literature, pricing and vendor's business card
"M" ACCOUNT STATUS DETERMINATION
Is this item for home care use?
Will this item be used for patient care?
Is this item disposable (for single patient use)?
Is this item a medically necessary part of the patient's current treatment?
QUESTIONS
Does/could this product replace a similar product currently in use?
Item #, Mfr Catalog #
Describe how the item will improve clinical care/outcomes if purchased.
Is item a patient/staff safety improvement?
Will item affect other departments/affiliates?
If item will affect other departments, have you communicated product information to them?
Will item require approval from another committee or department? (eg: Infection control, CES, Medical Staff, Nursing, Radiology, etc.)?
Will new/additional devices be needed to use this product? (ie: disposables, reusables)
Is an evaluation of the item necessary?
Has an evaluation tool, including outcomes and evaluation measures, been developed?
Will this item require a change in policy/procedure/protocol?
Would item require education for clinical staff?
Will this item have an affect on environmental resources? (eg: cleaning/disposal, storage)
Is this item FDA approved?
Do you have any interest in the selection of this item that may be deemed a conflict of interest?
Is there a cost-containment potential with the purchase of this item?
Fields marked with  « are required.
 
 
 

 

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