MAiD Practitioner and Pharmacist Documentation Submission

This submission page is intended for the use of Medical Assistance in Dying (MAiD) providers and pharmacists to submit MAiD documentation to the Ministry of Health to fulfill federal and provincial reporting obligations.

Note: If you are requesting MAiD, please complete the HLTH 1632 form or HLTH 1632 LARGE PRINT form and provide a copy to your physician or nurse practitioner, or send a copy of the form to the MAiD Care Coordination Service within your local health authority. Contact information for the MAiD Care Coordination Services can be found on the Forms for Medical Assistance in Dying page.

Practitioner or Pharmacist Name and at least one of Contact Phone Number or Contact Email Address are required to submit documentation

Practitioner or Pharmacist NameMissing or incorrect value

Contact Phone Number Missing or incorrect value

Contact Email AddressMissing or incorrect value

Notes

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This information is collected by the Ministry of Health under s:26{c) of the Freedom of Information and Protection of Privacy Act (FOIPPA) and will be used for the purposes of monitoring and oversight for the provision of Medical Assistance in Dying in British Columbia.

Should you have any questions about the collection of this personal information, please contact:

Medical Assistance in Dying Oversight Unit

PO Box 9638 STN PROV GOVT,

Victoria, BC V8W 9P1

Phone: 236-478-1915

Email: hlth.maidoversight@gov.bc.ca

HLTH 8118 2023/05/16

MAiD Practitioner and Pharmacist Documentation Submission

MAiD Practitioner and Pharmacist Documentation Submission

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