"Gender Affirming Surgery Approval Request Form / Application" - Nova Scotia, Canada

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Gender Affirming Surgery
Approval Request Form / Application
Health & Wellness
1 Provide your personal information
Last name:
First name:
Middle name:
Address:
Postal code:
Phone number:
Date of birth (yyyy/mm/dd):
MSI Health Card #:
__________________________________________ Expiry Date (yyyy/mm/dd): _______________________________
Email address ____________________________________________________________________
2 Complete patient declaration
I will be 18 years or older at the time of surgery
Yes
No
I am a permanent resident of Nova Scotia (NS)
Yes
No
I am registered with Medical Services Insurance (MSI) in NS and possess a valid MSI Health Card
Yes
No
My Physician, Nurse Practitioner (NP), Specialist or Health Care Provider (HCP) has explained the risks and complications associated with
Gender Affirming Surgery (GAS)
Yes
No
I understand that GAS surgical procedures are publicly funded only when they are pre-approved by MSI. The location where the procedure is
performed will be determined on a case by case basis and will depend upon the nature and extent of the surgery and the availability of surgical
expertise:
1.
The following procedures are available in Nova Scotia and only insured if performed in this province:
a.
Hysterectomy
b.
Oophorectomy
2.
The following procedures are available in both NS and at the Centre Metropolitain de Chirurgie in Montreal and may be insured at
both locations:
a.
Orchiectomy
b.
Penectomy
c.
Breast augmentation
d.
Mastectomy/Chest masculinization
3.
The following procedures are only available at the Centre Metropolitain de Chirurgie in Montreal and are only insured if performed
there:
a.
Phalloplasty
b.
Metoidoplasty
c.
Vaginoplasty
Yes
No
I understand that there is no public funding available for:
GAS services outside of Canada
Yes
No
GAS procedures not deemed medically necessary, such as, Facial Feminization, Liposuction, Tracheal
Shave, Voice Pitch Surgery
Yes
No
GAS services received without prior approval from MSI
Yes
No
Any services which are not insured by MSI
Yes
No
Any take-home medications, equipment, meals and other personal expenses
Yes
No
http://novascotia.ca/dhw/gender-affirming-surgery/
Page 1 of 4
GAS Out of Province Travel Form – November 15, 2019
Gender Affirming Surgery
Approval Request Form / Application
Health & Wellness
1 Provide your personal information
Last name:
First name:
Middle name:
Address:
Postal code:
Phone number:
Date of birth (yyyy/mm/dd):
MSI Health Card #:
__________________________________________ Expiry Date (yyyy/mm/dd): _______________________________
Email address ____________________________________________________________________
2 Complete patient declaration
I will be 18 years or older at the time of surgery
Yes
No
I am a permanent resident of Nova Scotia (NS)
Yes
No
I am registered with Medical Services Insurance (MSI) in NS and possess a valid MSI Health Card
Yes
No
My Physician, Nurse Practitioner (NP), Specialist or Health Care Provider (HCP) has explained the risks and complications associated with
Gender Affirming Surgery (GAS)
Yes
No
I understand that GAS surgical procedures are publicly funded only when they are pre-approved by MSI. The location where the procedure is
performed will be determined on a case by case basis and will depend upon the nature and extent of the surgery and the availability of surgical
expertise:
1.
The following procedures are available in Nova Scotia and only insured if performed in this province:
a.
Hysterectomy
b.
Oophorectomy
2.
The following procedures are available in both NS and at the Centre Metropolitain de Chirurgie in Montreal and may be insured at
both locations:
a.
Orchiectomy
b.
Penectomy
c.
Breast augmentation
d.
Mastectomy/Chest masculinization
3.
The following procedures are only available at the Centre Metropolitain de Chirurgie in Montreal and are only insured if performed
there:
a.
Phalloplasty
b.
Metoidoplasty
c.
Vaginoplasty
Yes
No
I understand that there is no public funding available for:
GAS services outside of Canada
Yes
No
GAS procedures not deemed medically necessary, such as, Facial Feminization, Liposuction, Tracheal
Shave, Voice Pitch Surgery
Yes
No
GAS services received without prior approval from MSI
Yes
No
Any services which are not insured by MSI
Yes
No
Any take-home medications, equipment, meals and other personal expenses
Yes
No
http://novascotia.ca/dhw/gender-affirming-surgery/
Page 1 of 4
GAS Out of Province Travel Form – November 15, 2019
Gender Confirming Surgery
Approval Request / Application
Health & Wellness
I have read and understand the Department of Health and Wellness (DHW) Out of Province Travel and Accommodation Assistance
Guidelines (if requesting approval for Chest Masculinization / Mastectomy, Phalloplasty, Metoidioplasty, Breast Augmentation, Penectomy,
Orchiectomy and Vaginoplasty for the purpose of GAS performed at the Centre Métropolitain de Chirurgie, Montreal, Quebec)
Yes
No
3 Sign the certification and consent—Patient
I certify that the information given on this form is complete and accurate.
I understand that my personal health information collected on this form and the attached supporting documents will only be used to process my
request and will not be disclosed without my consent unless required by the NS Personal Health Information Act (PHIA)
Name (please print):
Signature:
Date:
4 Complete Physician/ NP/ Specialist declaration
I have verified that the patient meets the following general criteria for GAS:
Patient is aware surgery cannot be performed until they are 18 years or older
Yes
No
Patient is a permanent resident of NS
Yes
No
Patient is registered with MSI in NS and possesses a valid MSI Health Card
Yes
No
Primary Clinical Criteria
I have verified that the patient has:
Persistent, well-documented gender dysphoria
Yes
No
Capacity to make a fully informed decision and to consent for treatment, including the following
criteria
Yes
No
Understands the procedure/s
o
Understands associated risk/s and complications
o
Has an aftercare / follow-up plan
o
Reasonably well controlled medical or mental health concerns, if they are present
Yes
No
Additional Criteria
The patient has no significant physical health problems that would contraindicate
or complicate the proposed surgery
Yes
No
The patient is psychologically prepared for surgery
Yes
No
The patient has realistic goals and expectations of the surgery
Yes
No
The patient is informed of and understands any alternative procedures
Yes
No
The patient has engaged in a responsible way with the assessment/treatment process
Yes
No
http://novascotia.ca/dhw/gender-affirming-surgery/
Page 2 of 4
GAS Out of Province Travel Form – November 15, 2019
Gender Affirming Surgery
Request for Out of Province Travel
Health & Wellness
Surgical Criteria
CHEST SURGERY
Chest Masculinization / Mastectomy
In addition to the approval request form / application signed by a NS Physician, NP or specialist, the patient has:
One letter signed by a NS Specialist (e.g. general or any other surgeon, psychiatrist, endocrinologist) recommending surgery
Yes
No
One letter (based on psychosocial assessment) signed by a HCP trained in the WPATH SoC. if the specialist is trained in WPATH SoC,
no additional support letter is required
Yes
No
Letter from Family Physician (confirming post-operative care)
Yes
No
Hormone therapy is not a pre-requisite
Yes
No
Breast augmentation
In addition to the approval request form / application signed by a NS Physician, NP or specialist, the patient has:
One letter signed by a NS Specialist (e.g. general or any other surgeon, psychiatrist, endocrinologist) recommending surgery
Yes
No
One letter (based on psychosocial assessment) signed by a HCP trained in the WPATH SoC. if the specialist is trained in WPATH SoC,
no additional support letter is required.
Yes
No
Letter from Family Physician (confirming post-operative care)
Yes
No
Had 12 continuous months of hormone therapy without satisfactory breast growth ( Tanner stage ≤ 2 )
Yes
No
GENITAL SURGERY
Removal
ectomy): Oophorectomy, Hysterectomy, Penectomy, Orchiectomy or
(
Reconstruction (plasty): Phalloplasty, Metoidioplasty, Vaginoplasty
In addition, to the approval request form / application signed by a NS Physician, NP or specialist the patient has:
One letter signed by a NS Specialist (e.g. general or any other surgeon, psychiatrist,
Yes
No
endocrinologist) recommending surgery
Two letters (based on psychosocial assessment) signed by HCP`s trained in the WPATH SoC. If the specialist is trained in WPATH SoC,
then only one additional letter is required
Yes
No
A letter from Family Physician (confirming post-operative care)
Yes
No
A letter from Physician supervising hormone therapy (if not covered by one of the above letters)
Yes
No
Had 12 continuous months of hormone therapy as appropriate to the patient`s gender roles (unless
there is medial contradiction, or inability / unwillingness to undergo hormone therapy)
Yes
No
Been living for 12 continuous months in a gender role that is congruent with their gender identity (As per WAPATH SoC, this criterion only
applies to reconstruction surgeries)
Yes
No
5 Inform patient of Out of Province Travel and Accommodation Assistance Guidelines, if
applicable
I have reviewed the Department of Health and Wellness’ Out of Province Travel and Accommodation
Assistance Guidelines with the patient
Yes
No
N/A
http://novascotia.ca/dhw/gender-affirming-surgery/
Page 3 of 4
GAS Out of Province Travel Form – November 15, 2019
Gender Confirming Surgery
Approval Request / Application
Health & Wellness
6. Sign the certification and consent—Physician/ NP/ Specialist
I certify that the information given on this form is complete and accurate
Name (please print):
Signature:
Date:
7 Return the form and attachments to:
For Staff Use Only
Medical Services Insurance (MSI)
230 Brownlow Ave
Authorized signature:
Dartmouth, NS, B3J 2S1
Questions? Call 1-800-563-8880
Date:
http://novascotia.ca/dhw/gender-affirming-surgery/
Page 4 of 4
GAS Out of Province Travel Form – November 15, 2019
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