Notice to end At Home Program School-Aged Extended Therapies

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 1-800-613-3232 or PO Box 9719 STN PROV GOVT, Victoria, BC V8W 9S5.

This form is used to notify the Medical Benefits program that you, as the parent or guardian of a child on the At Home Medical Benefits program, have decided to receive future School-Aged Extended Therapy, such as Occupational Therapy, Speech Language Therapy and/or Physiotherapy, from a Family Connection Centre and will no longer access School-aged Extended Therapies from Medical Benefits Program.

Massage Therapy and Chiropractic Therapy, if eligible, will continue to be available through the At Home Medical Benefits program.

If you have more than one authorization, you do not need to submit multiple notifications to end each therapy.

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)

Parent/Guardian's First NameMissing or incorrect valueLegal name

Middle Name(s)Legal name

Parent/guardian'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

When will services begin with your Family Connection Centre?

Year

Please check the following statements:

Missing or incorrect value

Next steps:

You will receive a letter in the mail which confirms the end date of funding. You may continue to use existing Medical Benefits approved Occupational Therapy, Speech Language Therapy or Physiotherapy services until that date.

Service Providers will continue to have 6 months from the date of service to submit an invoice.

You may decide after receiving services and supports from the Family Connections Centre to resume individualized School-Aged Extended Therapy. To do so, you will be asked to inform the Medical Benefits program in writing and to confirm that all Family Connection Centre services have ended.

Signature

Missing or incorrect valueSign above

Date signed

(yyyy/mm/dd)

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 end At Home Program School-Aged Extended Therapies

Print footer

Submission Instructions