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The Health
Forms site has been developed to improve access to the Ministry of Health
by providing online and PDF forms. New forms are
being posted as they are released, so please check back with us periodically.
This list contains
only the latest versions of the forms. Unless indicated otherwise, all
forms listed here are in PDF format. To avoid using outdated versions,
we recommend you not keep downloaded files on your hard drive.
Early
Childhood Education
(now with the Ministry of Children and Family Development)
Finance
and Decision Support
Ambulance
Billing
| HLTH# |
|
Form
Title |
| 1790 |
|
Appeal
Based on Income Assistance |
| 1791 |
|
Appeal
Based on Premium Assistance Coverage |
| 1792 |
|
Appeal
Based on Services Rendered Incommensurate to Fee as Prescribed |
| 1793 |
|
Appeal
Based on Delay on Invoicing - Over One Year |
| 1794 |
|
Appeal
Based on Delay on Invoicing (Where an Insurer or Other Person is
Responsible for Invoicing) |
Out of Province
Claims
Home
and Community Care
Medical
and Health Care Practitioners Forms
(for GP and Specialist Locum forms, see Rural Health
below)
| HLTH# |
|
Form
Title |
| 1908 |
|
Assignment
of MSP Payments
for Diagnostic Facility Services |
| 2769 |
|
Application
for Pre-Authorization of Payment -
Surgery for Alteration of Appearance |
| 2771 |
|
Application
for Teleplan Service - Opted Out |
| 2810 |
|
Insured
Out of Country Medical Services |
| 2820 |
|
Application
for Teleplan Service - Opted In |
| 2832 |
|
Application
for Direct Bank Payment |
| 2848 |
|
Practitioner
Registration Form |
| 2870 |
|
Assignment
of Payment |
| 2871 |
|
Encounter
Record Submission Authorization |
| 2991 |
|
Application
for MSP Billing Number (Physicians) |
| 2994 |
|
Application
for MSP Billing Number (Dentists) |
| 2996 |
|
Application
for MSP Billing Number (Midwives) |
| 2997 |
|
Application
for MSP Billing Number (Nurse Practitioners) |
| 4530 |
|
Medical
Practice Access to PharmaNet |
MSP
Forms
HLTH# |
|
Form
Title |
| 102 |
|
Application
for Enrollment |
| 107
|
|
Application
for Temporary Premium Assistance is now FIN 107 and is now administered
by the Ministry of Provincial Revenue. |
| 115 |
|
Baby
Enrollment/Addition of Newborn |
| 119 |
|
Application
for Regular Premium Assistance |
| 263 |
|
Application
for Addition of Family Members |
| 2811 |
|
CareCard
Replacement |
| 2814 |
|
Out-of-Country
Claim Form |
| 6759 |
|
Address
Change Notice (pdf)
(use if a mail-in form is preferred over the online submission
of a change of address (HLTH 7062 or 7063)
|
| 7062 |
|
Address
Change for Persons Moving Within BC (html) |
| 7063 |
|
Permanent
Move Outside BC (html) |
| 7073 |
|
New
Company Information Request (html) |
Group Administrator
Forms
| HLTH# |
|
Form
Title |
| 120 |
|
Application
for Premium Assistance |
|
166 |
|
Change
of Payer Application |
| 167 |
|
Group
Application Form |
| 170 |
|
Group
Change Form |
| 201 |
|
New
Company Information (Third Party Registration) |
| 217 |
|
Coverage
Cancellation |
| 1904 |
|
Notice
to Terminating Employees |
Mental
Health and Addictions
AIMS (Addiction
Information Management System)
CPIM (Client/Patient
Information Management)
Mental
Health Act Forms
| HLTH# |
|
Form
Title |
| 3501 |
|
Form
1: Request for Admission (Voluntary Patients) |
| 3502 |
|
Form
2: Consent for Treatment (Voluntary Patient) |
| 3503 |
|
Form
3: Medical Report (Examination of a Person Under 16 Years of Age,
Admitted at the Request of Parent or Guardian) (Renewal Certificate) |
| 3504 |
|
Form
4: Medical Certificate (Involuntary Admission)
|
| 3505 |
|
Form
5: Consent for Treatment (Involuntary Patient) |
| 3506 |
|
Form
6: Medical Report on Examination
of Involuntary Patient (Renewal Certificate) |
| 3507 |
|
Form
7: Application for Review Panel Hearing |
| 3508 |
|
Form
8: Review Panel Determination |
| 3509 |
|
Form
9: Application for Warrant
(Apprehension of Person with Apparent Mental Disorder for Purpose
of Examination) |
| 3510 |
|
Form
10: Warrant (Apprehension of Person with Apparent Mental Disorder) |
| 3511 |
|
Form
11: Request for Second Medical Opinion |
| 3512 |
|
Form
12: Medical Report (Second Medical Opinion) |
| 3513 |
|
Form
13: Notification to Involuntary Patient of Rights
Under the Mental Health Act |
| 3514 |
|
Form
14: Notification of Patient Under 16,
Admitted by a Parent or Guardian, of Rights Under the Mental
Health Act |
| 3515 |
|
Form
15: Nomination of Near Relative |
| 3516 |
|
Form
16: Notification to Near Relative (Admission of Involuntary Patient
or Patient Under Age 16) |
| 3517 |
|
Form
17: Notification to Near Relative (Discharge of Involuntary Patient) |
| 3518 |
|
Form
18: Notification to Near Relative
(Request or Order for a Review Panel Hearing) |
| 3519 |
|
Form
19: Certificate of Discharge |
| 3520 |
|
Form
20: Leave Authorization |
| 3521 |
|
Form
21: Director's Warrant (Apprehension of Patient) |
Nursing
Directorate Forms
| HLTH# |
|
Form
Title |
| 4359 |
|
LPN
Pharmacology Education Fund Application 2006-07 |
| 4361 |
|
RN
/ RPN Return to Nursing Fund Application 2006-07 |
| 4363 |
|
LPN
Leadership Program Fund 2006-07 |
PharmaCare
Forms
| HLTH# |
|
Form
Title |
| 5349 |
|
Fair
PharmaCare Registration |
| 5349 |
|
Fair
PharmaCare Registration - French |
| 5355 |
|
Application
for Income Review |
| 5357 |
|
Notarized
Affidavit |
Register
for Fair Pharmacare On-line
Special
Authority Request Forms
| HLTH# |
|
Form
Title |
| 5328 |
|
Special
Authority Request |
| 5332 |
|
Cyclosporine/Leflunomide
for Rheumatoid Arthritis |
| 5338 |
|
Low
Molecular Weight Heparin |
| 5341 |
|
Interferon
Alfa for Hepatitis B |
| 5342 |
|
Lamivudine
for Hepatitis B |
| 5345 |
|
Adalimumab/Etanercept/Infliximab
for Rheumatoid Arthritis
- Initial Coverage (12 Week Supply) |
| 5346 |
|
Adalimumab/Etanercept/Infliximab
for Rheumatoid Arthritis
- First Renewal (At 12 Weeks) |
| 5347 |
|
Infliximab
for Fistulizing Crohn's Disease Coverage |
| 5348 |
|
Infliximab
for Severe Active Crohn's Disease Coverage |
| 5350 |
|
Proton
Pump Inhibitors (PPIs) Request for Coverage |
| 5351 |
|
Disease
Modifying Drug Coverage for Multiple Sclerosis |
| 5352 |
|
Disease
Modifying Drug Coverage for Multiple Sclerosis - Change of Medication |
| 5353 |
|
Disease
Modifying Drug Coverage for Multiple Sclerosis -
Annual Therapy Review |
| 5354 |
|
Adalimumab/Etanercept/Infliximab
for Rheumatoid Arthritis
- Annual Renewal |
| 5356 |
|
Pegylated
Interferon/Ribavirin Coverage for the Treatment of Hepatitis C in
Naive Patients |
| 5358 |
|
Pioglitazone/Rosiglitazone
- PharmaCare Initial Coverage (26 week supply) |
| 5359 |
|
Pioglitazone/Rosiglitazone
- Renewal of PharmaCare Coverage |
Population
Health and Wellness
Regionalized
or Discontinued Forms
These forms
have been regionalized or discontinued. The Ministry of Health is no
longer responsible for the printing or storing of these forms. They
are posted on this site for the convenience of the Health Authorities
should the HA's wish to continue to use them.
Rural
Practice Programs
Rural GP Locum
Program
Rural Specialist
Locum Program
Vital
Statistics Agency Forms
Application for
Service
Application for Change of Name
Accessing Records
No Contact Declaration and Statement
Disclosure Veto and Statement
Rescind a Disclosure Veto or No Contact Declaration
Statutory Declaration and Undertaking
Wills Notice
Search of Wills Notice
PDF Format
Some documents on this Web site are in PDF format and require a PDF reader. If you do not have Adobe Acrobat Reader Version 7.0 or the most recent version of another PDF reader, you can download Adobe Acrobat Reader by selecting the 'Get Acrobat Reader' icon.
Last Revised:
November 16, 2006
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