Forms for Medical Assistance in Dying

Requestor Forms

Form # Form Name and Information

HLTH 1632

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

HLTH 1632
LARGE PRINT

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

Waiver of Final Consent (New)

Form # Form Name and Information

HLTH 1645

The form for a person to waive the requirement to give express consent immediately prior to receiving medical assistance in dying. Please consult with your doctor or nurse practitioner, regarding whether you meet the criteria to waive final consent.
For more information on the condition under which the Waiver of Final Consent may be used, 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 250-645-8549 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 Assisted Dying Program, Care Coordination
Vancouver Coastal Health
RM 309 - 2775 Heather Street
Vancouver BC  V5Z 3J5
Provincial Health Services Authority 1-844-851-6243 604-829-2631 MAiD Care Coordination Office Provincial Health Services Authority Suite 200, 1333 West Broadway
Vancouver, BC V5Z 4C2


Practitioner Forms

IMPORTANT NOTICE: As of March 17, 2021, new federal legislation on medical assistance in dying came into effect, including changes to eligibility criteria, safeguards, and processes for MAiD. The provincial forms have been updated to account for these changes, and these new forms must be used for any requests for MAiD submitted after this date. The new legislation includes a transitional provision for MAiD requests made prior to the new legislation coming into effect; for more information on the transitional provision and associated requirements, please consult this Guide to the Transitional Provision.

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.)

Note: This form is only for an assessment of capability to give informed consent. This form is not required for a consultation with a doctor or nurse practitioner with expertise in the condition causing the patient’s suffering.

 

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

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.

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.)​