PPAGE 1 AGE 1 OF OF 2CF2�58 (18/11)

AT HOME PROGRAM APPLICATION

The personal information collected on this form will be used for the purposes of determining At Home Program eligibility and providing benefits and will be treated confidentially in compliance with the Freedom of Information and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information should be directed to the Director, Child and Youth with Special Needs Branch, (250) 952-6044, PO Box 97�9 Stn Prov Govt, Victoria BC V8W 9S5.

A. To Be Completed By Parent Or GuardianLast Name of Child First Initial Child's Personal Health Number Gender Date of Birth (yyyy/mm/dd)

Name of Parent(s)/Guardian(s) Date of Birth (yyyy/mm/dd) Daytime Phone Number

( )Address City/Town Postal Code Evening Phone Number

( )Extended Health Benefits If Yes, Name of the Insurance Company

Registered Indian If Yes, Registration Number If Yes, Band Name and Number

All Household Members (excluding the child) Use back of page if you require more space.

Last Name First Name Relationship to Child Gender Date of BirthDate of Birth(yyyy/mm/dd)

Signature of Parent/Guardian (please appropriate box(es), initial each true statement and then sign in the signature area below)If my child is eligible for the At Home Program, I require: (if your child is eligible for one benefit, please indicate your preferred benefit)

♦respite benefits and/or medical benefits

InitialI am aware that the At Home Program (AHP) is intended to assist families who are facing extraordinary costs and care demands because of their children’s severe disabilities or complex health needs.

♦

InitialI am aware that any information I provide in relation to this application will be used by the Ministry of Children and Family Development to determine initial and continuing eligibility for AHP benefits.

♦

InitialMy child lives at home with me and I am the parent/legal guardian of the child.♦

InitialMy child is a resident of B.C. and has a legal right to reside permanently in Canada.♦

InitialMy child is not the beneficiary of or in receipt of a Court award or settlement and there has not been a Court judgment, award or settlement, arising from a personal injury claim, in favour of my child.

♦

InitialI agree to inform the AHP Regional Contact when there is a Court judgment, award or settlement, in favour of my child, arising from a personal injury claim.

♦

InitialI consent to the release of information contained in this application and related assessments to members of the Regional Eligibility Committee, to the local Health Authority and staff of the Ministry of Children and Family Development, who are responsible for providing medical or respite benefits for my child.

♦

Initial

Initial♦ I will inform the AHP Regional Contact of any change in any of the information provided in this application on the occurrence of the change.

Signature X Date (yyyy/mm/dd):

Primary Diagnosis Secondary Diagnosis

Signature Name (Please Print) Date (yyyy/mm/dd)

M F

YES NO

YES NO

Child Requires Palliative Services

Yes No

B. To Be Completed By The Child's Physician or Nurse PractitionerFor children to be eligible for the At Home Program they are required to be assessed as dependent in three of four areas of: eating, dressing, toileting and washing in relation to or because of their disability. By signing this form you are indicating that you believe the child has probable dependencies in the above noted areas.

Palliative Services Exception - AHP Palliative Benefits are available to B.C. children with active MSP coverage who: are living at home, have been diagnosed with a life-threatening illness or condition, and have a life expectancy of up to six months.

When Completed, Please Mail or Fax to your Local MCFD Office.

PPAGE AGE 2 OF OF 2CF2�58 (18/11)

Initial Application

Reassessment

Appeal

Not Eligible

Eligible

Respite Benefits

Medical Benefits

Choice

AT HOME PROGRAM APPLICATION REVIEW

A. Regional Eligiblity Committee RecommendationChild's Name

Meeting Date (yyyy/mm/dd) Review Date (yyyy/mm/dd)

Members Present

Functional CriteriaIndicate whether the child is dependent, close to dependent or not dependent in each area of daily living.

Eating:

Dressing:

Toileting:

Washing:

DiscussionIndicate the factors or other criteria considered in making the eligibility decision.

Region Effective Date (yyyy/mm/dd) AM Number

REGIONAL CONTACT SIGNATURE Name (Please Print) Date Signed (yyyy/mm/dd)

Not EligibleEligible Respite Medical

B. Eligibility Decision

Date of Birth (yyyy/mm/dd) Name of Parent(s)/Guardian(s)

At Home Program Info Sheet

November 2018

The At Home Program (AHP) assists parents with some of the extraordinary costs of caring for a child with severe disabilities at home, through a range of health supports and services.

Who is eligible for the AHP?

The AHP is intended for children with severe disabilities who are dependent in multiple areas of daily living. Children and youth who are assessed as dependent in three of four areas of daily living (eating, dressing, toileting and washing) are eligible for a choice of medical or respite benefits. Those who are dependent in all four areas are eligible for both benefits.

Children and youth who are considered to be palliative by a medical professional, those with certain degenerative conditions (Duchene’s Muscular Dystrophy, Spinal Atrophy Type II), and those receiving direct nursing care through Nursing Support Services are also eligible for one or both benefits.

Children and youth must be residents of British Columbia and must be enrolled with the British Columbia Medical Services Plan.

Children or parents in receipt of an insurance settlement or court award related to the child’s disability are not eligible for the At Home Program.

What services does AHP provide?

Respite Benefits

Provides funding to purchase respite care for eligible children. Families may choose the type of respite services that best suit their needs, either in their home or at another location.

Medical Benefits

Provides one or more of the following upon the recommendation of a relevant regulated health care professional: medically essential equipment and supplies; hearing aids; dental, optical and orthodontic services related to a disability; extended therapies for school-aged children; medical transportation; PharmaCare coverage; and premium-free MSP coverage.

How is an AHP application made?

The child or youth’s parent or guardian completes section A of the application form. A physician must complete section B. Send the completed form to an AHP Coordinator or speak to your local MCFD office. At Home Coordinator contact information is available at: https://www2.gov.bc.ca/assets/gov/family-and-social-supports/children-teens-with-special-needs/at_home_program_regional_contacts.pdf

For local CYSN office contact information, visit: https://www2.gov.bc.ca/gov/content/health/managing-your-health/healthy-women-children/child-behaviour-development/special-needs/complex-health-needs/at-home-program

Where can I find the application form?

Application forms are available at local Ministry of Children and Family Development offices, from local health units (the telephone number of your local health unit can be found in the blue pages of your telephone directory, or call Health Link BC at 811) or online at:https://www2.gov.bc.ca/assets/gov/family-and-social-supports/children-teens-with-special-needs/at_home_program_application.pdf

What’s the next step after application?

The AHP Coordinator will review the application and arrange for an assessment, if appropriate. A qualified assessor will contact the family and make an appointment to meet with the child or youth and his or her family. Should additional medical information be required, the AHP Coordinator or the assessor may also contact the referring physician or other health care professionals.

What is the Assessor’s role?

The assessor will arrange to visit the child or youth, preferably in the family home. The assessor will complete an assessment of the child or youth’s functional abilities in four areas of daily living: dressing, washing, toileting and eating. The assessor will send the assessment to the AHP Coordinator and will provide the parent or guardian with a copy for their records.

Who determines eligibility?

An AHP Regional Eligibility Committee comprised of MCFD staff, medical professionals and community members will review the application and assessment, and will determine eligibility based on established AHP eligibility criteria. The parent or guardian will receive a letter with the eligibility decision.

What if a child is not eligible?

If you do not agree with an eligibility decision, please contact your local At Home Program Regional Contact. If you have additional medical documentation that was not available during the assessment, submit it for reconsideration.

If you feel that you have not been treated fairly, or in a respectful manner, you may contact the Ministry of Children and Family Development's Client Relations Branch at 1 877 387-7027 (toll-free) or 250 387-7027 (Victoria) and inquire about the complaint resolution process.

For more information, access the At Home Program Guide or visit the program website at: www2.gov.bc.ca/athomeprogram