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177
![Form HTLH3497 "Application for Pharmacare Plan G" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2108/21087/2108704/form-htlh3497-application-for-pharmacare-plan-g-british-columbia-canada.png "Form HTLH3497 "Application for Pharmacare Plan G" - British Columbia, Canada")
Form HTLH3497 "Application for Pharmacare Plan G" - British Columbia, Canada
Size: 1 MB
2 pages
A prescribing physician or a nurse practitioner from British Colombia can complete and submit the application to allow individuals to become a part of a psychiatric medication plan.
!["Medical Services Plan (Msp) Application for Enrolment" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2108/21087/2108703/medical-services-plan-msp-application-for-enrolment-british-columbia-canada.png ""Medical Services Plan (Msp) Application for Enrolment" - British Columbia, Canada")
"Medical Services Plan (Msp) Application for Enrolment" - British Columbia, Canada
Size: 1 MB
4 pages
Individuals who reside in British Colombia may use this form when they would like to apply to enter the Medical Service Plan (MSP).
![Form HLTH3 "Service Authorization Action Memo" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2133/21338/2133871/form-hlth3-service-authorization-action-memo-british-columbia-canada.png "Form HLTH3 "Service Authorization Action Memo" - British Columbia, Canada")
![Form 5 (HLTH3505) "Consent for Treatment (Involuntary Patient)" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2133/21338/2133885/form-5-hlth3505-consent-for-treatment-involuntary-patient-british-columbia-canada.png "Form 5 (HLTH3505) "Consent for Treatment (Involuntary Patient)" - British Columbia, Canada")
![Form 16 (HLTH3516) "Notification to Near Relative (Admission of Involuntary Patient or Patient Under Age 16)" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2133/21339/2133905/form-16-hlth3516-notification-to-near-relative-admission-of-involuntary-patient-or-patient-under-age-16-british-columbia-canada.png "Form 16 (HLTH3516) "Notification to Near Relative (Admission of Involuntary Patient or Patient Under Age 16)" - British Columbia, Canada")
![Form 18 (HLTH3518) "Notification to Near Relative (Request for a Review Panel Hearing)" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2133/21339/2133909/form-18-hlth3518-notification-to-near-relative-request-for-a-review-panel-hearing-british-columbia-canada.png "Form 18 (HLTH3518) "Notification to Near Relative (Request for a Review Panel Hearing)" - British Columbia, Canada")
![Form 17 (HLTH3517) "Notification to Near Relative (Discharge of Involuntary Patient)" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2133/21339/2133907/form-17-hlth3517-notification-to-near-relative-discharge-of-involuntary-patient-british-columbia-canada.png "Form 17 (HLTH3517) "Notification to Near Relative (Discharge of Involuntary Patient)" - British Columbia, Canada")
![Form 15 (HLTH3515) "Nomination of Near Relative" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2133/21339/2133903/form-15-hlth3515-nomination-of-near-relative-british-columbia-canada.png "Form 15 (HLTH3515) "Nomination of Near Relative" - British Columbia, Canada")
![Form 12 (HLTH3512) "Medical Report (Second Medical Opinion)" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2133/21338/2133897/form-12-hlth3512-medical-report-second-medical-opinion-british-columbia-canada.png "Form 12 (HLTH3512) "Medical Report (Second Medical Opinion)" - British Columbia, Canada")
![Form 11 (HLTH3511) "Request for Second Medical Opinion" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2133/21338/2133895/form-11-hlth3511-request-for-second-medical-opinion-british-columbia-canada.png "Form 11 (HLTH3511) "Request for Second Medical Opinion" - British Columbia, Canada")
![Form 20 (HLTH3520) "Leave Authorization" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2133/21339/2133915/form-20-hlth3520-leave-authorization-british-columbia-canada.png "Form 20 (HLTH3520) "Leave Authorization" - British Columbia, Canada")
![Form 21 (HLTH3521) "Director's Warrant (Apprehension of Patient)" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2133/21339/2133917/form-21-hlth3521-director-s-warrant-apprehension-of-patient-british-columbia-canada.png "Form 21 (HLTH3521) "Director's Warrant (Apprehension of Patient)" - British Columbia, Canada")
![Form 19 (HLTH3519) "Certificate of Discharge" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2133/21339/2133913/form-19-hlth3519-certificate-of-discharge-british-columbia-canada.png "Form 19 (HLTH3519) "Certificate of Discharge" - British Columbia, Canada")
![Form HLTH103 "Medical Services Plan (Msp) Application for Supplementary Benefits" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2136/21366/2136642/form-hlth103-medical-services-plan-msp-application-for-supplementary-benefits-british-columbia-canada.png "Form HLTH103 "Medical Services Plan (Msp) Application for Supplementary Benefits" - British Columbia, Canada")
![Form HLTH170 "Medical Services Plan (Msp) Group Change Request" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2136/21366/2136696/form-hlth170-medical-services-plan-msp-group-change-request-british-columbia-canada.png "Form HLTH170 "Medical Services Plan (Msp) Group Change Request" - British Columbia, Canada")
![Form HLTH178 "Medical Services Plan (Msp) Enrolment Application" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2136/21366/2136653/form-hlth178-medical-services-plan-msp-enrolment-application-british-columbia-canada.png "Form HLTH178 "Medical Services Plan (Msp) Enrolment Application" - British Columbia, Canada")
![Form HLTH308 "Medical Services Plan (Msp) Change Request" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2136/21366/2136652/form-hlth308-medical-services-plan-msp-change-request-british-columbia-canada.png "Form HLTH308 "Medical Services Plan (Msp) Change Request" - British Columbia, Canada")
![Form HLTH302 "No Cardiopulmonary Resuscitation - Medical Order" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2136/21366/2136665/form-hlth302-no-cardiopulmonary-resuscitation-medical-order-british-columbia-canada.png "Form HLTH302 "No Cardiopulmonary Resuscitation - Medical Order" - British Columbia, Canada")
![Form HLTH296 "Beneficiary Submission for Extra Billing Investigation" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2136/21366/2136645/form-hlth296-beneficiary-submission-for-extra-billing-investigation-british-columbia-canada.png "Form HLTH296 "Beneficiary Submission for Extra Billing Investigation" - British Columbia, Canada")
![Form HLTH349 "Bc Palliative Care Benefits Registration" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2136/21365/2136556/form-hlth349-bc-palliative-care-benefits-registration-british-columbia-canada.png "Form HLTH349 "Bc Palliative Care Benefits Registration" - British Columbia, Canada")
![Form HLTH1.6 "Financial Profile and Calculations" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2133/21338/2133868/form-hlth1-6-financial-profile-and-calculations-british-columbia-canada.png "Form HLTH1.6 "Financial Profile and Calculations" - British Columbia, Canada")
![Form HLTH1.1 "Application and Assessment Form" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2133/21338/2133867/form-hlth1-1-application-and-assessment-form-british-columbia-canada.png "Form HLTH1.1 "Application and Assessment Form" - British Columbia, Canada")
![Form HLTH5391 "Special Authority Request - Apixaban/Dabigatran/Rivaroxaban for Atrial Fibrillation" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2138/21386/2138652/form-hlth5391-special-authority-request-apixaban-dabigatran-rivaroxaban-for-atrial-fibrillation-british-columbia-canada.png "Form HLTH5391 "Special Authority Request - Apixaban/Dabigatran/Rivaroxaban for Atrial Fibrillation" - British Columbia, Canada")
![Form HLTH4557 Schedule 24 "Additional Facilities Addendum for the Attestation of Compliance With the Government of British Columbia Wireless Standards" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2138/21386/2138656/form-hlth4557-schedule-24-additional-facilities-addendum-for-the-attestation-of-compliance-with-the-government-of-british-columbia-wireless-standards-british-columbia-canada.png "Form HLTH4557 Schedule 24 "Additional Facilities Addendum for the Attestation of Compliance With the Government of British Columbia Wireless Standards" - British Columbia, Canada")
![Form HLTH4556 Schedule 23 "Attestation of Compliance With the Government of British Columbia Wireless Standards" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2138/21386/2138657/form-hlth4556-schedule-23-attestation-of-compliance-with-the-government-of-british-columbia-wireless-standards-british-columbia-canada.png "Form HLTH4556 Schedule 23 "Attestation of Compliance With the Government of British Columbia Wireless Standards" - British Columbia, Canada")
![Form HLTH4555 Schedule 22 "Attestation of Compliance With the Government of British Columbia Wireless Standards - Pharmacy" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2138/21386/2138653/form-hlth4555-schedule-22-attestation-of-compliance-with-the-government-of-british-columbia-wireless-standards-pharmacy-british-columbia-canada.png "Form HLTH4555 Schedule 22 "Attestation of Compliance With the Government of British Columbia Wireless Standards - Pharmacy" - British Columbia, Canada")
![Form HLTH4558 Schedule 22A "Re-attestation of Compliance With the Government of British Columbia Wireless Standards - Pharmacy" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2138/21386/2138655/form-hlth4558-schedule-22a-re-attestation-of-compliance-with-the-government-of-british-columbia-wireless-standards-pharmacy-british-columbia-canada.png "Form HLTH4558 Schedule 22A "Re-attestation of Compliance With the Government of British Columbia Wireless Standards - Pharmacy" - British Columbia, Canada")
![Form HLTH4554 Schedule 21 "Attestation of Compliance With the Government of British Columbia Wireless Standards - Medical Practice" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2138/21386/2138654/form-hlth4554-schedule-21-attestation-of-compliance-with-the-government-of-british-columbia-wireless-standards-medical-practice-british-columbia-canada.png "Form HLTH4554 Schedule 21 "Attestation of Compliance With the Government of British Columbia Wireless Standards - Medical Practice" - British Columbia, Canada")
![Form HLTH5482 "Pharmacare Special Authority Request - Alemtuzumab (Lemtrada) for Multiple Sclerosis" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2136/21366/2136612/form-hlth5482-pharmacare-special-authority-request-alemtuzumab-lemtrada-for-multiple-sclerosis-british-columbia-canada.png "Form HLTH5482 "Pharmacare Special Authority Request - Alemtuzumab (Lemtrada) for Multiple Sclerosis" - British Columbia, Canada")
![Form HLTH1622 "Assisted Living Registrar - Reportable Incident Report" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2136/21365/2136513/form-hlth1622-assisted-living-registrar-reportable-incident-report-british-columbia-canada.png "Form HLTH1622 "Assisted Living Registrar - Reportable Incident Report" - British Columbia, Canada")
![Form HLTH5349 "Fair Pharmacare Plan Registration" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2136/21365/2136557/form-hlth5349-fair-pharmacare-plan-registration-british-columbia-canada.png "Form HLTH5349 "Fair Pharmacare Plan Registration" - British Columbia, Canada")
![Form HLTH5355 "Fair Pharmacare Plan - Application for Income Review" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2136/21365/2136558/form-hlth5355-fair-pharmacare-plan-application-for-income-review-british-columbia-canada.png "Form HLTH5355 "Fair Pharmacare Plan - Application for Income Review" - British Columbia, Canada")
![Form HLTH5483 "Special Authority Request - Rifaximin" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2136/21365/2136598/form-hlth5483-special-authority-request-rifaximin-british-columbia-canada.png "Form HLTH5483 "Special Authority Request - Rifaximin" - British Columbia, Canada")
Form HLTH5483 "Special Authority Request - Rifaximin" - British Columbia, Canada
Size: 463 KB
1 page
![Form HLTH5551 "Consent for Release of Pharmanet Patient Record" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2136/21366/2136640/form-hlth5551-consent-for-release-of-pharmanet-patient-record-british-columbia-canada.png "Form HLTH5551 "Consent for Release of Pharmanet Patient Record" - British Columbia, Canada")
![Form HLTH5510 "Notification of Addition/Removal of Authorized Users" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2136/21365/2136549/form-hlth5510-notification-of-addition-removal-of-authorized-users-british-columbia-canada.png "Form HLTH5510 "Notification of Addition/Removal of Authorized Users" - British Columbia, Canada")
![Form HLTH5375 "Continuous Subcutaneous Insulin Infusion (Insulin Pump)" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2136/21366/2136621/form-hlth5375-continuous-subcutaneous-insulin-infusion-insulin-pump-british-columbia-canada.png "Form HLTH5375 "Continuous Subcutaneous Insulin Infusion (Insulin Pump)" - British Columbia, Canada")
![Form HLTH5393 "Pharmacare Special Authority Request - Rituximab for Granulomatosis With Polyangiitis or Microscopic Polyangiitis" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2136/21366/2136620/form-hlth5393-pharmacare-special-authority-request-rituximab-for-granulomatosis-with-polyangiitis-or-microscopic-polyangiitis-british-columbia-canada.png "Form HLTH5393 "Pharmacare Special Authority Request - Rituximab for Granulomatosis With Polyangiitis or Microscopic Polyangiitis" - British Columbia, Canada")
![Form HLTH5373 "Special Authority Request - Rituximab for Rheumatoid Arthritis - Initial/Renewal" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2136/21365/2136587/form-hlth5373-special-authority-request-rituximab-for-rheumatoid-arthritis-initial-renewal-british-columbia-canada.png "Form HLTH5373 "Special Authority Request - Rituximab for Rheumatoid Arthritis - Initial/Renewal" - British Columbia, Canada")
![Form HLTH5362 "Special Authority Request - Inhalers for Chronic Obstructive Pulmonary Disease (Copd)" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2136/21366/2136614/form-hlth5362-special-authority-request-inhalers-for-chronic-obstructive-pulmonary-disease-copd-british-columbia-canada.png "Form HLTH5362 "Special Authority Request - Inhalers for Chronic Obstructive Pulmonary Disease (Copd)" - British Columbia, Canada")
![Form HLTH1908 "Diagnostic Facility Services Assignment of Payment & Medical Director Authorization" - British Columbia, Canada](https://data.templateroller.com/pdf_docs_html/2136/21366/2136657/form-hlth1908-diagnostic-facility-services-assignment-of-payment-medical-director-authorization-british-columbia-canada.png "Form HLTH1908 "Diagnostic Facility Services Assignment of Payment & Medical Director Authorization" - British Columbia, Canada")
