Form VSA510P "Physician's or Psychologist's Confirmation of Change of Gender Designation" - British Columbia, Canada

ADVERTISEMENT
ADVERTISEMENT

Download Form VSA510P "Physician's or Psychologist's Confirmation of Change of Gender Designation" - British Columbia, Canada

Download PDF

Fill PDF online

Rate (4.7 / 5) 7 votes
Page background image
This form is fillable. To begin, click in the Surname field.
Print
Clear form
PHYSICIAN’S OR PSYCHOLOGIST’S CONFIRMATION OF
CHANGE OF GENDER DESIGNATION
SHADED AREA FOR OFFICE USE ONLY
AFS# :
PHYSICIAN’S OR PSYCHOLOGIST’S INFORMATION
(Please print clearly)
Surname Followed by Given Name(s)
Mailing Address
Postal Code
Title (if any)
Telephone # (include area code)
(
)
DECLARATION OF PHYSICIAN OR PSYCHOLOGIST
The physician’s or psychologist’s declaration is in support of the request to change the applicant’s “Sex” designation on their provincially
issued identification by witnessing or certifying that the person identifies him/herself as a particular gender.
1.
I hereby certify that I am:
a practising registrant of the College of Physicians and Surgeons of British Columbia. BC MSP # ________________________
a practising registrant of the College of Psychologists of British Columbia. Registrant # ________________________________
a practising registrant, authorised in another province or territory, to practise a health profession equivalent to that practised by
person referred to above.
Your profession and registration # _________________________________________________
(Please provide copy of licence.)
)
(
2.
I support the application of
Applicant’s Name
Applicant’s Personal Health #
and (______________________________________) who is requesting the change in gender designation
BC Driver’s License # or BC Identification
FROM
q
Female
q
Male
q
X
TO
q
Female
q
Male
q
X
3.
I confirm that the applicant’s gender identity does not align with the “Sex” designation on the applicant’s provincial government-
issued identification.
4.
I understand the consequences of making a false declaration.
X
Signature of Physician or Psychologist
Date (dd/mm/yyyy)
Making a false or misleading statement on this form may result in prosecution under section 69 of the Motor Vehicle Act. A person who contravenes
section 69 is liable to a fine of up to $20,000 and/or to imprisonment.
PROVINCIAL GOVERNMENT-ISSUED IDENTIFICATION
This form may be used to support changes to the “Sex” field on all of the following provincial government-issued identification held by the applicant:
*
• BC Birth Certificate
• Enhanced Driver’s Licence
*
• BC Driver’s Licence
• Enhanced Identification Card
• BC Identification Card
• Photo BC Services Card
• Combined BC Driver’s Licence and Services Card
• Non-Photo BC Services Card
*
An "X" designation is NOT currently available on these cards.
Clear form
Print
VSA 510p 2018/08/17
PAGE 1 OF 2
This form is fillable. To begin, click in the Surname field.
Print
Clear form
PHYSICIAN’S OR PSYCHOLOGIST’S CONFIRMATION OF
CHANGE OF GENDER DESIGNATION
SHADED AREA FOR OFFICE USE ONLY
AFS# :
PHYSICIAN’S OR PSYCHOLOGIST’S INFORMATION
(Please print clearly)
Surname Followed by Given Name(s)
Mailing Address
Postal Code
Title (if any)
Telephone # (include area code)
(
)
DECLARATION OF PHYSICIAN OR PSYCHOLOGIST
The physician’s or psychologist’s declaration is in support of the request to change the applicant’s “Sex” designation on their provincially
issued identification by witnessing or certifying that the person identifies him/herself as a particular gender.
1.
I hereby certify that I am:
a practising registrant of the College of Physicians and Surgeons of British Columbia. BC MSP # ________________________
a practising registrant of the College of Psychologists of British Columbia. Registrant # ________________________________
a practising registrant, authorised in another province or territory, to practise a health profession equivalent to that practised by
person referred to above.
Your profession and registration # _________________________________________________
(Please provide copy of licence.)
)
(
2.
I support the application of
Applicant’s Name
Applicant’s Personal Health #
and (______________________________________) who is requesting the change in gender designation
BC Driver’s License # or BC Identification
FROM
q
Female
q
Male
q
X
TO
q
Female
q
Male
q
X
3.
I confirm that the applicant’s gender identity does not align with the “Sex” designation on the applicant’s provincial government-
issued identification.
4.
I understand the consequences of making a false declaration.
X
Signature of Physician or Psychologist
Date (dd/mm/yyyy)
Making a false or misleading statement on this form may result in prosecution under section 69 of the Motor Vehicle Act. A person who contravenes
section 69 is liable to a fine of up to $20,000 and/or to imprisonment.
PROVINCIAL GOVERNMENT-ISSUED IDENTIFICATION
This form may be used to support changes to the “Sex” field on all of the following provincial government-issued identification held by the applicant:
*
• BC Birth Certificate
• Enhanced Driver’s Licence
*
• BC Driver’s Licence
• Enhanced Identification Card
• BC Identification Card
• Photo BC Services Card
• Combined BC Driver’s Licence and Services Card
• Non-Photo BC Services Card
*
An "X" designation is NOT currently available on these cards.
Clear form
Print
VSA 510p 2018/08/17
PAGE 1 OF 2
RESOURCES FOR PHYSICIANS OR PSYCHOLOGISTS
For additional resources, professionals may refer to the guidelines established by the World Professional Association for Transgender
Health (WPATH), Standards of Care at www.wpath.org.
PRIVACY INFORMATION
When this form is submitted to Health Insurance BC and/or the Insurance Corporation of BC, the applicant’s personal information is
collected to update his/her Medical Services Plan (MSP), and/or the provincial government-issued identification listed in the box above.
Legislation Governing the Collection of Personal Information
• The Insurance Corporation of BC collects personal information under the authority of section 25 of the Motor Vehicle Act,
sections 3 and 9 of the Identification Card Regulation, and section 26 of the Freedom of Information and Protection of Privacy Act
(FIPPA). Information may be disclosed pursuant to section 33 of FIPPA.
• Health Insurance BC collects information under the authority of the Medicare Protection Act and section 26 of FIPPA. Information
may be disclosed pursuant to section 33 of FIPPA.
• The BC Vital Statistics Agency collects information on this form under section 26(c) of the Freedom of Information and Protection
of Privacy Act, and uses it to fulfill the requirements of the Vital Statistics Act for the release of gender designation information.
Should you have any questions about the collection of this personal information, please contact:
Manager, Vital Statistics Agency, 250 952-2681, PO Box 9657, Stn Prov Govt, Victoria BC V8W 9P3.
If you have questions about the collection and use of personal information for changing a BC Services Card or BC Driver’s Licence,
contact:
Manager, Service Delivery
Provincial Identity Information Management Program
PO Box 9412 STN PROV GOVT
Victoria, BC V8W 9V1
Telephone:
Victoria
250 387-6121
Vancouver
604 660-2421
Toll free in B.C.
1 800 663-7867
If you have questions about the collection and use of personal information for changing gender designation on a birth registration,
contact Vital Statistics, Confidential Services at 250 952-2681.
This form is subject to verification and audit by the Province of British Columbia and the Insurance Corporation of BC.
PAGE 2 OF 2
VSA 510p 2018/08/17
Page of 2