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

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Gender Affirming Surgery
Approval Request Form / Application
Health & Wellness
PERSONAL INFORMATION
Last Name___________________________________________________________________________
Preferred Name____________________________ Pronoun(s): ________________________________
First name: _____________________________
Middle name(s): _____________________________
Address: ____________________________________________________________________________
Postal Code: ____________________
Phone number: ___________________
Date of birth: (yyyy/mm/dd): ___________________________
MSI Health Card #: ___________________________
Expiry Date (yyyy/mm/dd): ________________
Email address: ________________________________________________________________________
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:
Yes
No
1. The following procedures are available in Nova Scotia and only insured if performed in this province:
a. Hysterectomy
b. Oophorectomy
é
e
2. The following procedures are available in both NS and at the Centre M
tropolitain de Chirurgi
in Montréal and
may be insured at both locations:
a. Orchiectomy
b. Penectomy
c. Breast Augmentation
d. Mastectomy/Chest Masculinization
é
3. The following procedures are only available at the Centre M
tropolitain de Chirurgie in Montréal and are only
insured if performed there:
a. Phalloplasty
b. Metoidoplasty
c. Vaginoplasty
I understand that there is no public funding available for:
GAS services outside of Canada
Yes
No
Procedures sometimes performed with GAS, such as, Facial Feminization,
Liposuction, Tracheal Shave, Voice Pitch Surgery are not insured by MSI
Yes
No
Gender Affirming Surgery
Approval Request Form / Application
Health & Wellness
PERSONAL INFORMATION
Last Name___________________________________________________________________________
Preferred Name____________________________ Pronoun(s): ________________________________
First name: _____________________________
Middle name(s): _____________________________
Address: ____________________________________________________________________________
Postal Code: ____________________
Phone number: ___________________
Date of birth: (yyyy/mm/dd): ___________________________
MSI Health Card #: ___________________________
Expiry Date (yyyy/mm/dd): ________________
Email address: ________________________________________________________________________
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:
Yes
No
1. The following procedures are available in Nova Scotia and only insured if performed in this province:
a. Hysterectomy
b. Oophorectomy
é
e
2. The following procedures are available in both NS and at the Centre M
tropolitain de Chirurgi
in Montréal and
may be insured at both locations:
a. Orchiectomy
b. Penectomy
c. Breast Augmentation
d. Mastectomy/Chest Masculinization
é
3. The following procedures are only available at the Centre M
tropolitain de Chirurgie in Montréal and are only
insured if performed there:
a. Phalloplasty
b. Metoidoplasty
c. Vaginoplasty
I understand that there is no public funding available for:
GAS services outside of Canada
Yes
No
Procedures sometimes performed with GAS, such as, Facial Feminization,
Liposuction, Tracheal Shave, Voice Pitch Surgery are not insured by MSI
Yes
No
Gender Affirming Surgery
Approval Request Form / Application
Health & Wellness
PATIENT DECLARATION (cont’d)
I understand that there is no public funding available for:
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
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, Montréal, Quebec)
Yes
No
N/A
CERTIFICATION AND PATIENT CONSENT
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)
Legal Name (please print): _________________________________________________________
Signature: ____________________________________
Date: _____________________
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
o
Understands the procedure(s)
o
Understands associated risk(s) and complications
o
Has an aftercare / follow-up plan
Reasonably well controlled medical or mental health concerns, if they are present
Yes
No
Gender Affirming Surgery
Approval Request Form / Application
Health & Wellness
PHYSICIAN / NP / SPECIALIST DECLARATION (cont’d)
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
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) supporting surgery
Yes
No
One letter (based on psychosocial assessment) signed by an HCP trained in the WPATH
SoC. (no additional support letter is required if the Specialist is trained in WPATH SoC)
Yes
No
Letter from Family Physician or NP (confirming post-operative care)
(letter required from surgeon performing surgery if performed in NS)
Yes
No
Hormone therapy is not a pre-requisite
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) supporting surgery
Yes
No
One letter (based on psychosocial assessment) signed by an HCP trained in the WPATH
SoC. (no additional support letter is required if the Specialist is trained in WPATH SoC)
Yes
No
Letter from Family Physician or NP (confirming post-operative care)
(letter required from surgeon performing surgery if performed in NS)
Yes
No
Had 12 continuous months of hormone with breast growth less than and equal to
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,
endocrinologist) supporting surgery
Yes
No
Two letters (based on psychosocial assessment) signed by HCPs trained in the WPATH
SoC. (no additional support letter is required if the Specialist is trained in WPATH SoC)
Yes
No
Gender Affirming Surgery
Approval Request Form / Application
Health & Wellness
PHYSICIAN / NP / SPECIALIST DECLARATION (cont’d)
A letter from Family Physician or NP (confirming post-operative care)
Yes
No
(letter required from surgeon performing surgery if performed in NS)
A letter from Physician or NP monitoring 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
Yes
No
gender identity
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
Yes
No
N/A
Travel and Accommodation Assistance Guidelines with the patient
CERTIFICATION AND CONSENT —PHYSICIAN / NP / SPECIALIST
I certify that the information given on this form is complete and accurate.
Name (please print): _________________________________________________________
Signature: ____________________________________
Date: _____________________
RETURN THE FORM AND ATTACHMENTS TO:
Medical Services Insurance (MSI)
230 Brownlow Ave
Dartmouth, NS, B3J 2S1
Questions? Call 1-800-563-8880
For Staff Use Only
Authorized signature:
Date:
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