FHSC New Product / Service Request

Use this form to request a new product or service. This form is to be completed by the requesting Physician, Manager or Supervisor. Submissions from shared computers are subject to author validation and may be rejected.

Request Title*

Include Name and Vendor of product/service

Request Decription*

Please enter a short description of this request

Priority

High

Low

DOS*

Date services are needed/expected

Provider Information

Provider Name*

Provider Practice

Provider Phone*

Provider Email*

Purpose Request

Type of Request*

Is this a new product request or new procedure request

Select

Purpose of Request:*

Please select the purpose for this request

Patient Specific

Clinical Evaluation

Future/Ongoing Use

Provider Compensation

Will you receive a fee to use this product?

Yes

No

Provider Financial Interest

Do you have financial conflict or interest in selecting and/or recommending this Product?

Yes

No

New Procedure Request

Procedure Name*

Procedure Details*

Please identify any specific needs

New Procedure*

Is this a new procedure?

Yes

No

Performed this procedure before?

Have you performed this procedure before?

Yes

No

Where was this procedure done before?

Name/Location of facility/hospital

Performed this procedure at FHSC in the past?*

Yes

No

Date Previously completed at FHSC*

if so when?

New Skills

Does this product require new skills/credentials or privleges?

Yes

No

PROC New skills certification/credentials

Include any certification or credentials for this type of procedure.

Freestanding ASC

Is this procedure being done at freestanding ASC's?

Yes

No

Anesthesia

Are there specific anesthesia concerns or expertise required?

Yes

No

Anesthesia Concerns*

Pharmacy or Diagnostic Imaging Requirement

Is there a new pharmacy or diagnostic?

Yes

No

Special Equipment or Procedures

Are there specific equipment, procedure or personnel that are required for adoption?

Yes

No

Addtiional info:

Please include details:

New Product Request

(Please provide any supportive documentation)

Product Name

Product Manufacturer

Alternate/Competing Products

Are you aware of an alternative or competing product to the one you wish to utilize?

Yes

No

Alternate Products

Please identify any alternative or competing products and manufacturers

Product Technology

Is this new technology?

New

Existing

Product FDA HDE or IDE

Does this product have an HDE or IDE from the FDA?

Yes

No

N/A

Product Data Collected

Will data be collected in regard to the use of this product for research or study?

Yes

No

Product Replacement

Will this product replace an existing product?

Yes

No

Product Replaced

If this product is to replace an existing product, please identify the existing product that would be replaced

Patient Outcomes

How will this product improve patient outcomes?

Existing Product Usage

Will this product increase or decrease usage of an existing product?

Increase

Decrease

Same

N/A

Patient Volume Changes

Will this product increase patient volume?

Increase

Decrease

Same

N/A

Projected Patient Volumes

If this product changes patient volumes, please project anticipated monthly volume

Vendor Details

REP Name

REP Phone

REP Email

Proctor Required

Yes

No

REP Proctor

If a Proctor is required, please identify who

Billing/Reimbursement

Procedure Codes*

Please list all CPT codes for this procedure

Reimb Insurance Payer*

Specific Billing Codes

Are implants/equipment used that require specific codes for billing?

Yes

No

N/A

Reimb Implant codes*

Additional Notes

Notes

Include any additional information that may help or support you request.

Send me a copy of my responses

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