PharmaCare forms

Fair PharmaCare

Before using the paper or PDF version of the form, consider registering online so you can get temporary coverage right away. Using a paper registration form is the slowest way to register.

Online:

• Register for Fair PharmaCare
• Fair PharmaCare Income Review
• Request Fair PharmaCare Consent Form
• Request Confirmation of your Fair PharmaCare Assistance

Paper:

• AHLTH 101 - Application for BC Health and Drug Coverage (PDF, 2.5MB)
• HLTH 5355 - Income Review Application (PDF, 143KB)
• HLTH 5357 - Fair PharmaCare Proof of Income Affidavit (PDF, 763KB)
• HLTH 5409 - Fair PharmaCare Plan: Current Year Income Declaration for Canada-Ukraine Authorization for Emergency Travel (CUAET) Arrivals (PDF, 754KB)
• HLTH 5408 - Emergency BC PharmaCare Coverage for Ukrainian Arrivals form (PDF, 1MB)

Plan W

• HLTH 5480 - First Nations Health Benefits Out-of-Province Claim (PDF, 92KB)

PharmaNet record

• HLTH 5550 - Request to Inactivate Adverse Reaction/Clinical Condition on PharmaNet Profile (PDF, 936KB)
• HLTH 5551 - Consent for Release of PharmaNet Patient Record (PDF, 998KB)
• HLTH 5461 - Application to Restrict Access to My Own PharmaNet Record (PDF, 693 KB)​
• HLTH 5462 - Application to Restrict Access to Another Person's PharmaNet Record (PDF, 705KB)
• Health Gateway

• HLTH 349 - BC Palliative Care Benefits Program Application (PDF, 389KB)
• HLTH 3497 - Application for PharmaCare Plan G (No Charge Psychiatric Medication Program Plan) (PDF, 534KB)
• HLTH 5408 - Emergency BC PharmaCare Coverage for Ukrainian Arrivals form (PDF, 1MB)

Special Authority

• Special Authority Request Forms
• Special Authority Drug List
• Collaborative Prescribing Agreements—available for specific Limited Coverage drugs as noted in the Practitioner Exemptions section under that drug's coverage criteria

• HLTH 4571 - Plan W OTC Recommendation (PDF, 932KB)
• HLTH 5378 - Frequent Dispensing Authorization (PDF, 1.1MB)
• HLTH 5425 - Compound Costing Worksheet (PDF, 955KB)
• HLTH 5464 - BC Smoking Cessation Program Declaration and Notification (PDF, 532KB)
• HLTH 5499 - Application for Exceptional Plan Z Coverage (PDF, 505KB)
• HLTH 5550 - Request to Inactivate Adverse Reaction/Clinical Condition on PharmaNet Profile (PDF, 976KB)

• HLTH 5400 - Orthotic Benefits Application for Financial Assistance (PDF, 652KB)
• HLTH 5402 - Prosthetic Benefits Application for Financial Assistance (PDF, 597KB)
• HLTH 5404 - Prosthetic Benefits (Non-Limb) Application for Financial Assistance (PDF, 530K)
• HLTH 5415 - Mastectomy Benefits Invoice (PDF, 512KB)
• HLTH 5416 - Ostomy Benefits Invoice (PDF, 512KB)
• HLTH 5417 - Prosthetic and Orthotic Benefits Invoice (PDF, 512KB)
• HLTH 5418 - Offloading Orthotic Benefits Application for Financial Assistance (PDF, 2.2MB)
• HLTH 5433 - Provider Change (PDF, 746KB)
• HLTH 5450 - Orthotic Benefits - Plagiocephaly Helmet (PDF, 147KB)
• HLTH 5467 - Eligibility: Awards and Settlements (PDF, 1.06MB)

• Drug Product Request Form for Biosimilars (PDF, 1.56MB)
• BC Generic Drug Listing Terms and Conditions (PDF, 372KB)

• HLTH 5384 - Application for PharmaCare Rural Incentive Program (PDF, 1.06MB)
• HLTH 5432 - PharmaCare Provider Enrolment (PDF, 585KB)
• HLTH 5432A - Schedule A: Owner Details (PDF, 513KB)
• HLTH 5432B - Schedule B: Additional Sites (PDF, 512KB)
• HLTH 5432C - Schedule C: Additional Information (PDF, 498KB)

PRIME

• PRIME - Practitioner enrolment
• PRIME - Registering a private community health practice

PharmaNet

• HLTH 4567 - Notification of Emergency Access to PharmaNet for Professionals in Health Care Settings—this form is available only on request from Health Insurance BC.
• HLTH 5550 - Request to Inactivate Adverse Reaction/Clinical Condition on PharmaNet Profile (PDF, 930KB)

Undertakings of confidentiality

• HLTH 4548 - Undertaking to Complete Confidentiality Procedures for Hospital Access to PharmaNet (PDF, 621KB)
• HLTH 4551 - Acknowledgement of Completion of Confidentiality Procedures for Medical Device Distributor Claims Access to PharmaNet (PDF, 597KB)
• HLTH 4559 - Emergency Department Access to PharmaNet: Acknowledgement of Completion of Confidentiality Procedures (PDF, 637KB)

Attestations of compliance

• HLTH 4554 - Attestation of Compliance with the Government of British Columbia Wireless Standards - Medical Practice [Schedule 21] (PDF, 655KB)
• HLTH 4555 - Attestation of Compliance with the Government of British Columbia Wireless Standards - Pharmacy [Schedule 22] (PDF, 652KB)
• HLTH 4556 - Attestation of Compliance with the Government of British Columbia Wireless Standards - Emergency Department, Hospital, Designated Mental Health Facility [Schedule 23] (PDF, 649KB)
• HLTH 4557 - Additional Facilities for the Attestation of Compliance with the Government of British Columbia Wireless Standards - Emergency Department [Schedule 24] (PDF, 595KB)
• HLTH 4558 - Re-Attestation of Compliance with the Government of British Columbia Wireless Standards - Pharmacy [Schedule 22A] (PDF, 651KB)