Health benefits medical transportation request form - First Nations 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Part 1 – Client Information. Fill in your surname, first and middle names, status number, BC Health Care Card number, date of birth, address, telephone number, city, province/territory, and postal code.
3. Move to Part 2 – Escort Information. Indicate if an escort is required by selecting 'YES' or 'NO'. If applicable, provide the escort's name and date of birth.
4. In Part 3 – Health Practitioner / Health Facility Information, enter the name of your health practitioner or facility along with their telephone number and address. Specify their specialty and appointment dates/times.
5. Proceed to Part 4 – Travel Information / Mode of Transportation. Fill in the departure and return dates, locations transported from/to, and select the type of transportation used.
6. Complete Part 5 – Accommodation by indicating the type of accommodation needed and check-in/check-out dates. Specify if two beds or a wheelchair-accessible room is required.
7. Finally, in Part 6 – Authorization and Signature, authorize the release of records by signing and dating the form. Ensure all necessary attachments are included before submission.

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