To Be Completed by the User:



It is HealthEast’s policy that all new products and equipment must be reviewed and approved by the HealthEast Value Analysis Program and/or the HealthEast Clinical Co-Management Committee prior to purchase for use. This form must be completed for review of new products.

It is HealthEast’s policy that all new procedures must be approved by the HealthEast Board of Directors prior to performing the requested procedure. This form must be completed for review.

|General Information |

|Site Requesting: St. Joe’s St. John’s Woodwinds Midway |

|Request Type: Trial (free one time use) New Product New Procedure |

|Product Information |

|Product Description:       |

|Manufacture:       |Model#       |

|Manufacture/Supplier Contact Name:       | Phone:       |

| |Product/Procedure Information |

|C | |

|L | |

|I | |

|N | |

|I | |

|C | |

|I | |

|A | |

|N | |

|MUST | |

|COMPL| |

|ETE | |

| |Physician/Requested By:       | Date:       |

| |(Name & Signature) | |

| |What procedure(s) would this product be used for? or, What is the new procedure being requested?       |

| |Estimated Monthly Usage of New Product?:       |

| |Impact on Outcome |

| |Clinical Benefit(s):       |

| | |

| | |

| |Impact on length of stay:       |

| | |

| |Impact on procedure time:       |

| | |

| |Other Impacts:       |

| | |

| |Is there a comparable product/procedure in the HealthEast System now? (i.e. What will this product/procedure be used in place of?) |

| | |

| |No Yes, If “Yes” (Explain):       |

| |Have you ever used this product before/ Have you ever performed this procedure before? |

| | |

| |No Yes, If “Yes” (where?):       |

| |Conflict of Interest? Please disclose any financial interest (direct or indirect beneficial interest in the product/manufacturer) |

| |      |

|Approval/Signatures |

|1. Approved for further review? (Director Level) No Yes [NA for Level 1] |

|2. Approved By Core Group? No Yes [NA for Level 1] |

|3. Approved for Entry? (Director Level) No Yes |

|If not approved, why:       |

|Surgery Director 1st Signature:       Date:       |

| |

|Surgery Director 2nd Signature:       Date:       |

Please fax completed form to Materials Management at the following numbers:

Orthopedic, Spine, Neuro Products 651-326-8372

All other Surgery Products 651-326-8508

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