Forms for Medical Assistance in Dying
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Patient Form
Form # | Form Name and Information |
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HLTH 1632 |
The form for a patient to submit their request for medical assistance in dying. |
Practitioner Forms
Form # | Form Name and Information |
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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 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
Fraser Health |
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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: The form should not be sent to a health authority or the BC Coroners Service. |
VSA 406A |
Medical Certification of Death - Vital Statistics Agency
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For the prescribing medical or nurse practitioner to report a death resulting from medical assistance in dying to the BC Coroners Service. |
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HLTH 1636 |
For the prescribing medical or nurse practitioner to use when submitting all required forms for medical assistance in dying to the BC Coroners Service. |
HLTH 1637 |
Patient Confirmation Record |
MAiDTTAP Forms
(Medical Assistance in Dying Travel and Training Assistance Program)
Form # | Form Name and Information |
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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.) |