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The information on this form is collected under the Income and Employment Supports Act or the Assured Income for the Severely Handicapped Act.
The data provided is managed in accordance with the Health Information Act and the Freedom of Information and Protection of Privacy Act.
The form requires detailed patient information including name, date of birth, personal health number, and contact details.
All requested drugs and nutritional products must have a Drug Identification Number or Natural Product Number assigned by Health Canada.
Prescribers must indicate if they can access drug samples for a trial period and whether they are involved in formal drug trials with manufacturers.
There is a section for additional information that may assist the Health Benefits Exception Committee in making funding decisions.
The form must be signed by the prescriber to validate the request for prescription or non-prescription drugs.
