Funding Application For Out Of Province Mental Health And Or Addictions

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Funding ApplicAtion
For out-oF-province
MentAl HeAltH And/or Addictions
Send form to:
Out-of-Province Claims
Application must be completed by the attending psychiatrist or
2-1, 1515 Blanshard Street
addictions specialist with a recent consultation report attached.
Victoria BC V8W 3C8
Phone: 250 952-1334
Fax: 250 952-1940
pHysiciAn
Referring Physician
Phone Number
Fax Number
Mailing Address
Signature of Referring Physician
Date Signed
pAtient
Patient Last Name
Patient First Name
BC Personal Health (CareCard) Number
Birthdate
out-oF-province treAtMent progrAM
Facility Name
Facility Location (City, Province)
Program Name
Treatment Length (# of days)
diAgnosis, AssessMent And MedicAl History
1. Is the patient mentally alert, medically stable and able to participate in residential treatment?
Yes
No
If no, please explain:
2. Does the patient demonstrate significant impairment in functioning as a direct result of severe mental illness or substance abuse in
any of the following categories?
a) Social
Yes
No
b) Family
Yes
No
c) Occupational
Yes
No
If no in any or all of the above categories, please explain:
HLTH 2809 2010/08/12
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