Notice to change service and supports from Family Connections Centre to Autism Funding

The personal information collected on this form will be used for the purpose of providing funds through the At Home Medical Benefits Program and 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 Medical Benefits Community Liaison/Quality Assurance Officer, toll free at 1-888-613-3232 or PO Box 9763 STN PROV GOVT, Victoria, BC V8W 9S5.

This form is used to notify the Autism Funding program that you, as the individual that has signed the Autism Funding Agreement, have decided to end services and supports from a Family Connections Centre and resume Autism Funding.

If your child has not received Autism Funding in the past please review Autism Funding application process.

Note: If you have multiple children receiving Autism Funding, you must submit a separate form for each child.

Child's first nameMissing or incorrect valueLegal name

Child's middle name(s)Legal name

Child's last nameMissing or incorrect valueLegal name

Date of birth

Missing or incorrect value(yyyy/mm/dd)

The parent/guardian is the individual that has signed the Autism Funding Agreement:

Agreement signatory's first nameMissing or incorrect valueLegal name

Agreement signatory's middle name(s)Legal name

Agreement signatory's last nameMissing or incorrect valueLegal name

What is your current mailing address?Missing or incorrect value

What is your email address?Missing or incorrect value

Confirm email address:Missing or incorrect value

What is the name of your Primary Support Coordinator?Missing or incorrect value

When will services with your Family Connections Centre end?

Missing or incorrect value

You will receive a letter confirming the start date of Autism Funding. You may submit new Request to Pay Service Providers/Suppliers forms along with this notification.

You will be solely responsible for amounts invoiced for autism intervention services or for equipment purchased prior to restart date of your child's Autism Funding.

Signature

Missing or incorrect value

Date signed

To submit your application, click the Email button below when all required information is provided. A copy of this form will be emailed to the address you provided above. Please wait up to 15 minutes for your confirmation email to arrive.

Notice to change service and supports from Family Connections Centre to Autism Funding

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Information Collection, Use or Disclosure

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