Ostomy/Urinary Cath V1 (Mar 2017) Retention Period: 30 days from data entry date 1 of 2 Week(s) Qty Max Qty Code Max 2/MO 2/MO SOS-0025 5/WK 2/MO SOS-0026 5/WK 2/MO SOS-0027 5/WK 2/MO SOS-0028 5/WK 2/MO SOS-0029 5/WK 2/MO SOS-0030 5/WK 2/MO SOS-0031 5/WK 2/MO SOS-0032 5/WK 2/MO SOS-0033 5/WK 2/MO SOS-0034 5/WK 2/MO 2/MO SOS-0035 5/WK SUR-0030 2/MO SOS-0036 5/WK 2/MO 2/MO SOS-0037 5/WK 2/MO SOS-0038 5/WK 2/MO SOS-0039 5/WK 2/MO SOS-0040 5/WK 35/WK SOS-0041 5/WK 35/WK SOS-0042 5/WK 35/WK SOS-0043 5/WK 35/WK SOS-0044 5/WK SOS-0045 5/WK 1/WK SOS-0046 5/WK 1/WK 1/WK SOS-0047 5/WK 2/MO SOS-0048 5/WK 2/MO SOS-0049 5/WK SOS-0050 5/WK 2/MO SOS-0051 5/WK 2/MO SOS-0052 5/WK 2/MO SOS-0053 5/WK 2/MO SOS-0065 1/Pt Medline Medline Medline Medline Medline 10mLBalloon 10mLBalloon 10mLBalloon Red Flat Cut-to-Fit Coupling/Flange 50mm (2") Product Description Brand Size As per policy, CCAC approval must be obtained PRIOR to submitting form if any of the following are applicable to this order: 1) Quantities exceed maximums; 2) Non-regular delivery type for active patients; or 3) Specialty items as identified with: "(‡)" CCAC Approver Name: Rationale: Code Product Description Brand Size URINARY SUPPLIES FOLEY CATHETERS SUR-0001 2 Way Hydrogel Coated Latex 12Fr BARD Can 5mL Balloon Delivery Time: Regular Delivery URBAN (Next Day) Regular Delivery RURAL (< 48 Hrs) OSTOMY SUPPLIES & ACCESSORIES Ostomy Skin Barriers for 2 Piece System-SenSura Mio Click (Coloplast) Same Day URBAN (‡) Same Day RURAL (‡) Weekend URBAN (‡) Weekend RURAL (‡) MAXIMUM FOR OSTOMY FLANGES AND BAGS IS 10/PATIENT/ADMISSION Next Day RURAL(‡) Immediate Delivery URBAN (‡) Frequency: Q: Delivery To: Patient Pick-Up at Depot (Specify Depot ): Patient Private-Pay Home Delivery Order Type: New Admission Frequency Change Change in Orders Renewal: Health Card # (optional) Patient Contact Phone Number and Address MEDICAL SUPPLIES ORDER FORM - OSTOMY / URINARY CATHETERS CCAC Patient Surname CCAC Patient First Name CCAC Client # or BRN # SUR-0015 2 Way Hydrogel Coated Latex 16Fr 30mLBalloon SUR-0004 2 Way Hydrogel Coated Latex 18Fr BARD Can 5mL Balloon SUR-0014 2 Way Hydrogel Coated Latex 14Fr BARD Can 30mLBalloon BARD Can INTERMITTENT CATHETERS SUR-0112 2 Way Hydrogel Coated Latex 18Fr 2 Way Hydrogel Coated Latex 20Fr 2 Way 100% Silicone 12 Fr 2 Way 100% Silicone 14Fr 2 Way 100% Silicone 16Fr 2 Way 100% Silicone 18Fr 2 Way 100% Silicone 16Fr 2 Way 100% Silicone 18Fr 2 Way 100% Silicone 20Fr Female Intermittent Catheter 10 Fr SUR-0029 SUR-0032 BARD Can BARD Can 30mLBalloon 30mLBalloon 10mLBalloon 30mLBalloon 30mLBalloon 30mLBalloon Medline Medline URINARY LEG BAGS SpeediCath 10 Fr x 9 cm SUR-0113 SUR-0114 SUR-0115 Female Intermittent Catheter 12 Fr Female Intermittent Catheter 14 Fr SpeediCath SpeediCath SpeediCath 12 Fr x 9 cm 14 Fr x 9 cm 12-18 Fr 30cm Male Intermittent Catheter 12-18 Fr Medline 19oz/600mL SUR-0086 SUR-0089 SUR-0090 SUR-0094 Medline Medline Medline Medline Leg Bag Twist Valve w/Straps Leg Bag Twist Valve w/Straps Drainage Bag w/Anti-Reflux Tower & Metal Drain Clamp Urinary Leg Bag Extention Tubing Pouch Convex Deep Cut-to-Fit Stoma Size 10-23mm (3/8"-7/8") Yellow Flat Cut-to-Fit Coupling/Flange 70mm (2 3/4") Green Convex Light Cut-to-Fit Coupling/Flange 40mm (1 9/16") Red Convex Light Cut-to-Fit Coupling/Flange 50mm (2") Blue Convex Light Cut-to-Fit Coupling/Flange 60mm (2 3/8") StatLock StatLock StatLock StatLock 19oz/600mL 32oz/1100mL Yellow Convex Light Cut-to-Fit Coupling/Flange 70mm (2 3/4") Universal Foley Cath Stabilization Universal Plus Cath Stabilization-L Universal Plus Cath Stabilization-M Universal Plus Cath Stabilization-S SUR-0085 SenSura Mio Click Green Coupling/Flange 40mm (1 9/16") SenSura Mio Click Red Coupling/Flange 50mm (2") SenSura Mio Click Blue Coupling/Flange 60mm (2 3/8") SenSura Mio Click Yellow Coupling/Flange 70mm (2 3/4") One Piece Urostomy System-SenSura Mio (Coloplast) Pouch Convex Light Cut-to-Fit Stoma Size 10-23mm (3/8"-7/8") Pouch Convex Light Cut-to-Fit Stoma Size 15-33mm (5/8"-1 1/4") Pouch Convex Light Cut-to-Fit Stoma Size 10-43mm (3/8"-1 3/4") Green Convex Deep Cut-to-Fit Coupling/Flange 40mm (1 9/16") Red Convex Deep Cut-to-Fit Coupling/Flange 50mm (2") Blue Convex Deep Cut-to-Fit Coupling/Flange 60mm (2 3/8") Yellow Convex Deep Cut-to-Fit Coupling/Flange 70mm (2 3/4") Urostomy Pouches for 2 Piece System (Coloplast) SenSura Mio Click Green Coupling/Flange 40mm (1 9/16") Drainable Pouches for 2 Piece System (Coloplast) SenSura Mio Click Red Coupling/Flange 50mm (2") Pouch Convex Deep Cut-to-Fit Stoma Size 15-33mm (5/8"-1 1/4") Pouch Convex Deep Cut-to-Fit Stoma Size 10-43mm (3/8"-1 3/4") Pouch Flat Cut-to-Fit Stoma Size 10-55mm (3/8"-1 1/8") Pouch Convex Light Cut-to-Fit Stoma Size 10-23mm (3/8"-7/8") One Piece System with Drainable Pouches-SenSura Mio (Coloplast) Pouch Convex Light Cut-to-Fit Stoma Size 15-33mm (5/8"-1 1/4") Pouch Convex Light Cut-to-Fit Stoma Size 10-43mm (3/8"-1 3/4") Leg Bag Kit Twist Valve w/Straps & 18"Tubing 2000 mL 18 inches Each 12-14 Fr 10-12 Fr 6- 8.5 Fr CATHETER STABILIZATION SUR-0111 SUR-0104 Pouch Convex Deep Cut-to-Fit Stoma Size 10-23mm (3/8"-7/8") Pouch Convex Deep Cut-to-Fit Stoma Size 15-33mm (5/8"-1 1/4") Pouch Convex Deep Cut-to-Fit Stoma Size 10-43mm (3/8"-1 3/4") SUR-0105 SUR-0106 OSTOMY KIT (Coloplast) Ostomy Care Kit (1/Pt admission) For further NE CCAC medical supplies information always refer to the most updated medical supplies list on the NE CCAC website. SUR-0117 2 Way Red Latex Tiemann Coude Tip BARD Can 5 mL 16 Fr SUR-0118 2 Way 100% Silicone Coude Tip Medline 10 mL 14 Fr SUR-0033 SUR-0034 SUR-0016 SUR-0017 SUR-0027 SUR-0028 SUR-0002 2 Way Hydrogel Coated Latex 14Fr BARD Can 5mL Balloon SUR-0003 2 Way Hydrogel Coated Latex 16Fr BARD Can 5mL Balloon SUR-0119 2 Way 100% Silicone Coude Tip Medline 10 mL 16 Fr SUR-0116 2 Way Red Latex Tiemann Coude Tip BARD Can 5 mL 14 Fr