Notice to resume 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 1-888-613-3232 or PO Box 9763 STN PROV GOVT, Victoria, BC V8W 9S5.

This form is used to notify the At Home Program that you, a the parent or guardian of a child on the At Home Program, have decided to end services and supports from a Family Connections Centre and resume School-Aged Extended Therapies.

If your child has not received At Home School-Aged Extended Therapies in the past please review the At Home Program application process.

Child's first nameMissing or incorrect value

Child's middle name(s)

Child's last nameMissing or incorrect value

Date of birth

Missing or incorrect value(yyyy/mm/dd)

Parent/guardian's first nameMissing or incorrect value

Parent/guardian's middle name(s)

Parent/guardian's last nameMissing or incorrect value

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 that School-Aged Extended Therapy can resume. Your therapist(s) may submit new Requests for School-Aged Extended Therapy forms along with this notification.

You will be solely responsible for amounts invoiced for therapy services purchased prior to restart date of your child's School-Aged Extended Therapy.

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 resume At Home Program School-Aged Extended Therapies

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Information Collection, Use or Disclosure

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