Application for At Home Program Medical Benefits

CF2160 Application for At Home Program Medical Benefits

At Home Program Medical Benefits Application for CYSN Pilot Areas

The personal information collected on this form will be used for the purposes of determining At Home Program Medical Benefits eligibility and providing benefits. This information will be treated confidentially in compliance with the Freedom of Information and Protection of Privacy Act. Any questions about the collection, use, or disclosure of this information should be directed to the Community Liaison Quality Assurance Officer, Specialized Provincial Services, 1 888-613-3232, PO Box 9763 Stn Prov Govt, Victoria BC V8W 9S5.

This form is intended for families living in the following regions: Kelowna, Prince Rupert, Terrace and Smithers. More information is available here

Application check list:

If any of the required documents listed below are missing, the processing of your application could be delayed or denied.

Application:

Assessments are not required in the following circumstances:

If the child/youth has a palliative condition, is receiving Nursing Support Services or has been diagnosed with Duchenne Muscular Dystrophy or Spinal Muscular Atrophy Type 1 or Type 2, then the following assessments are not required.

Assessment(s) included as part of this application:

Important: Section A must be completed prior to Sections B and C

Instructions for Section A - To be completed by the parent/guardian online*

*See 'How to convert to PDF' below if Section A cannot be completed online

Ensure all required (*) fields are completed and ensure the information such as spelling of name and date of birth match the child/youth and parent/guardian's photo ID attached to the application..

Ensure all statements have been checked as true and then sign and date the form.

Once section A is complete convert the form to PDF (instructions below) then either email or bring the form to your physician, pediatrician, nurse practitioner or pediatric specialist for them to complete Sections B and C.

Instructions for Section B - To be completed by physician, pediatrician, nurse practitioner or pediatric specialist

Once you receive the emailed/hard copy application form from the parent/guardian, please complete sections B and C and ensure all required (*) fields are completed.

If the child/youth is under 3 years of age, there must be strong likelihood that they will have a long-term disability. This means the child/youth’s current condition is expected to result in significant limitations in their adaptive functioning, mobility and or daily living activities and there is a strong likelihood they will continue to have these limitations as they get older.

If the child/youth is over 3 years of age, outline and describe the child/youth’s need for consistent and permanent medical equipment to support their mobility, positioning, and/or assist life sustaining functions. This can include the current and future needs of the child/youth. If you do not know the full scope of the child/youth’s medical equipment needs a letter of attestation from the child/youth’s Occupational Therapist/Physiotherapist can be included.

Instructions for Section C - To be completed by physician, pediatrician, nurse practitioner or pediatric specialist

If there is any additional supporting information regarding the child/youth’s medical diagnosis that you didn't provide in the prior sections, please provide it here. If the box provided is not large enough, please attach a separate document.

Ensure each statement has been confirmed with all required initials, then sign and date the form.

Once complete, return the form to the parent or guardian.

Submission

Please submit the completed application by email, fax, or mail. Please include any assessments as indicated below, and copies of government-issued identification for both the child/youth and parent/guardian:

a copy of parent/guardian's government-issued identification
a copy of child/youth's government-issued identification
a copy of child/youth's BC Services Card

Email: MCF.MedicalBenefitsProgram@gov.bc.ca

Mailing: PO Box 9763 STN PROV GOVT Victoria, BC V8W 9S5

FAX: 250-356-2159

If you have any questions, please call us at 1-888-613-3232 or 250-387-9649.

How to convert to PDF:

Select 'PDF' button at the bottom of the form to:

Save and email application to your child/youth's physician, pediatrician, nurse practitioner or pediatric specialist or to complete the application by hand.
Select 'Print' or save the document to chosen location, then open and email or print.

If completing application by hand:

Ensure all handwriting is clear and legible so there are no delays when processing the form
Ensure copies of government-issued identification for child/youth/parent/guardian are attached
Ensure all required (*) fields are completed and ensure the spelling of names and dates of birth match the child/youth's and parent/guardian's photo ID provided.

Child/youth's first nameMissing or incorrect value

Child/youth's middle name(s)

Child/youth's last nameMissing or incorrect value

Child/youth's date of birth

Missing or incorrect value

Child/youth's Personal Health NumberMissing or incorrect valuePlease enter the PHN as XXXX XXX XXX

Does this child/youth have Extended Health Benefits? Missing or incorrect value

If yes, what is the name of the insurance company that provides health coverage?

Is your child/youth currently receiving services from a local family connection centre?Missing or incorrect value

If yes, what is the name of the family connection centre?

This child/youth is:Missing or incorrect value

First nameMissing or incorrect value

Last nameMissing or incorrect value

Date of birth

Missing or incorrect value

Primary email address

Primary phone number Missing or incorrect value

Secondary phone number

What is the best way to contact you?Missing or incorrect value

AddressMissing or incorrect value

CityMissing or incorrect value

Postal codeMissing or incorrect value

Please click the (+) to add more members. Use the dropdown (▼) for more options.

First name

Last name

Date of birth

Relationship to child/youth

Missing or incorrect value

Typed signatures are not acceptedParent/Guardian signature

Missing or incorrect value

Date signed

Please note: If this application is submitted without an assessment and one is required, At Home Program Medical Benefits staff will contact the parent or guardian directly to advise on how to receive an assessment from their local family connection centre.

Is there anything else about the child/youth's medical diagnosis or condition which you think we should be aware of?

* Initial

Typed signatures are not accepted* Signature

* Date signed (YYYY/MM/DD)

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Application for At Home Program Medical Benefits

Print Footer

Information Collection, Use or Disclosure

Instructions to complete this form:

Section A: To be completed by Parent/Guardian

Child/youth's Information

Parent/Guardian Contact Information

List All Other Household Members

Please confirm that the following statements are true:

Section B: To be completed by child/youth's physician, pediatrician, nurse practitioner or pediatric specialist

Section C: To be completed by child/youth's physician, pediatrician, nurse practitioner or pediatric specialist