Forms for Medical Assistance in Dying

Patient Form

Form # Form Name and Information

HLTH 1632

The form for a patient to submit their request for medical assistance in dying.
For more information on submitting the Patient Request form, see the Medical Assistance in Dying page.

HLTH 1632
LARGE PRINT

The form for a patient to submit their request for medical assistance in dying. This form is in large, 14pt type.
For more information on submitting the Patient Request form, see the Medical Assistance in Dying page.

 

Medical Assistance in Dying Care Coordination Services in BC

Health Authority Phone Fax Mailing Address
Fraser HA 604-587-7878 604-523-8855 Medical Assistance in Dying Care Coordination Centre
Fraser Health Central City Tower
4th Floor, 13450 - 102nd Avenue
Surrey BC  V3T 0H1
Interior HA 1-844-469-7073 250-469-7066

Medical Assistance in Dying Care Coordination Service
Interior Health Community Health and Services Centre
505 Doyle Avenue, 3rd Floor
Kelowna BC  V1Y 0C5
Island HA 1-877-370-8699 250-519-3669 Care Coordination Service, Medical Assistance in Dying
c/o Victoria General Hospital, #1 Hospital Way
Victoria BC  V8Z 6R5
Northern HA 250-645-6417 250-565-2640 Care Coordinator, Medical Assistance in Dying
Northern Health
600 - 299 Victoria Street
Prince George BC  V2L 5B8
Vancouver Coastal HA 1-844-550-5556 1-888-865-2941 Care Coordination Service, Assisted Dying Program
Vancouver Coastal Health
855 12th Avenue West, #CP-380
Vancouver BC  V5Z 1M9
Provincial Health Services Authority 1-888-875-3256 604-829-2631 PHSA Medical Assistance in Dying Office
Suite 202 - 601 West Broadway
Vancouver BC  V5Z 4C2


Practitioner Forms

Form # Form Name and Information

HLTH 1633

For the assessing medical or nurse practitioner to record details of their assessment of a patient’s eligibility for medical assistance in dying.

HLTH 1634

For the prescribing medical or nurse practitioner to record details of their assessment of a patient’s eligibility and details related to the planning and administration of medical assistance in dying.
HLTH 1642

For a practitioner to record details of their transfer of a patient’s written request for medical assistance in dying to another practitioner or health authority MAiD Care Coordination Service.

HLTH 1635

For a consulting practitioner to record details of their assessment of a patient’s capability to make an informed consent decision regarding medical assistance in dying. (To be used only if one or both assessors have reason to be concerned regarding a patient's capability to provide informed consent.)
 

Prescription and Medication Administration Record

  • The BC Medical Assistance in Dying Prescription form (including the Pre-Printed Order and the Medication Administration Record) and the British Columbia Pharmacy Protocols guidance document are not available for general distribution. These documents can be accessed by the prescribing practitioner through the College of Physicians and Surgeons of British Columbia or through each health authority’s Care Coordination Centre.

Fraser Health
Interior Health
Island Health
Northern Health
Provincial Health Services Authority
Vancouver Coastal Health
HLTH 5466

For the prescribing medical or nurse practitioner to use when drugs need to be purchased from a community pharmacy, in order for patients to get 100% coverage. The form should be submitted as soon as possible, to ensure approval before the drugs are required. The special authority is approved for a period of 60 days, which can be extended upon request.

The form should be faxed to the Ministry of Health PharmaCare Special Authority branch at 1-800-609-4884, along with the following completed sections of the BC Medical Assistance in Dying Prescription form:
 - Identification and Declaration section
 - Intravenous Drug Protocol section
 - Oral Drug Protocol section

The form should not be sent to a health authority or the BC Ministry of Health fax number for reporting on medical assistance in dying.
VSA 406A

Medical Certification of Death - Vital Statistics Agency

  • A medical or nurse practitioner must complete the Medical Certification of Death within 48 hours of death in compliance with Section 18 of the Vital Statistics Act and provide the completed form to the Funeral Director so that a Disposition Permit may be issued.
    To order additional VSA 406A forms, fax or email the Vital Statistics Agency. Stockroom Fax: 250 952-9094. Email: HLTH.VSstock@gov.bc.ca
HLTH 1636

Document Submission Checklist

  • This form has been retired. Practitioners and pharmacists can view the MAiD Reporting at a Glance one-page reference sheet for details on forms submission.
HLTH 1637

Patient Confirmation Record

  • This form has been retired. Patient confirmation is now recorded on the Assessment Record (Prescriber) form (HLTH 1634).

Pharmacist Form

Form # Form Name and Information

HLTH 1641

For the pharmacist who dispenses a substance in connection with the provision of medical assistance in dying, to record details pertaining to the dispensing and return of unused medications.

 

MAiDTTAP Forms

(Medical Assistance in Dying Travel and Training Assistance Program)

Form # Form Name and Information
HLTH 1638

For the Coordinator of a health authority’s MAiD Care Coordination Service to complete and submit to Rural Programs, Ministry of Health, to request funding approval for a physician to travel to a rural/isolated community to conduct an eligibility assessment or provide medical assistance in dying.

(Note:  Funding request may include a mentorship training opportunity for local physician(s) willing to train with visiting physician in assessment or provision of MAiD.)
HLTH 1639

For the visiting physician to complete and submit to Rural Programs, Ministry of Health, for reimbursement of travel costs and travel related expenses for approved travel to a rural/isolated community to conduct an eligibility assessment or provide medical assistance in dying.

(Note:  Travel approval is sought by the health authority’s MAiD Care Coordination Service, using the HLTH 1638 form.)
HLTH 1640

For a local physician to complete and submit to Rural Programs, Ministry of Health, to receive payment for participating in an approved mentored training opportunity with a visiting physician in eligibility assessment or provision of medical assistance in dying.

(Note:  Training approval is sought by the health authority’s MAiD Care Coordination Service, using the HLTH 1638 form.)
HLTH 1643

For the Coordinator of a health authority’s MAiD Care Coordination Service to complete and submit to Rural Programs, Ministry of Health, to request Vising Mentor funding approval for a physician to travel to a rural/isolated community to provide support and mentorship to the Local Physician's first provisions.​

(Note: Funding request is only for MAiD Visiting Mentors who are providing support and mentorship. For MAiD physicians providing assessment or provision, please use form HLTH 1638.)​