Odsp Special Diet Form <90% AUTHENTIC>

Here is the content you need for the ODSP Special Diet Form (formally the Special Diet Allowance Application ). This information is typically filled out by a physician or nurse practitioner. Important Note: This is the required wording and medical criteria needed to justify the allowance. Do not just write "needs Ensure." You must use the specific clinical indicators listed below.

ODSP Special Diet Allowance – Clinician’s Content Section 1: Patient Information

Patient Name: [Insert Name] ODSP Member ID: [Insert ID] Date of Birth: [Insert DOB]

Section 2: Diagnoses Requiring Therapeutic Diet List the primary medical condition(s) requiring a specialized diet. Diagnosis 1: [e.g., Chronic Kidney Disease (Stage 4)] Diagnosis 2: [e.g., Celiac Disease] Diagnosis 3: [e.g., Type 2 Diabetes with Gastroparesis] Section 3: Specific Diet Prescribed & Clinical Indicators Check all that apply and include the mandatory clinical evidence. 1. High Protein odsp special diet form

[ ] Required for: Pressure ulcers, burns, cancer cachexia, HIV/AIDS, nephrotic syndrome, or malabsorption. Clinical evidence: Low serum albumin (<35 g/L) OR significant unintentional weight loss (>5% in 1 month).

2. High Calorie

[ ] Required for: Pre-transplant, cystic fibrosis, COPD with emphysema, hyperthyroidism. Clinical evidence: BMI < 18.5 OR documented >10% weight loss in 3 months. Here is the content you need for the

3. Low Fat (Fat Malabsorption)

[ ] Required for: Chronic pancreatitis, biliary cirrhosis, cystic fibrosis, Crohn’s disease (strictures). Clinical evidence: Quantitative fecal fat >7g/day OR pancreatic insufficiency (fecal elastase <100).

4. Low Carbohydrate (Diabetes or Hypoglycemia) Do not just write "needs Ensure

[ ] Required for: Brittle diabetes, gestational diabetes, recurrent hypoglycemic unawareness. Clinical evidence: HBA1c > 8.5% OR documented episodes of severe hypoglycemia requiring ER visit.

5. Low Sodium (No Added Salt)