Plan G Formulary
If patient signs, only page 1 is needed.

Otherwise, click below for Exceptional Coverage if no MSP, or if patient does not/cannot sign, and complete page 2.
Patient unwilling/unable to sign. Or patient does not have MSP coverage. Complete page 2 please.
Verbal Declaration
Legal authority:
MHSUC Sites CYMH Sites
Subject:
Creative Commons License created February 12 2016 by Dr. John Robertson, licensed under a GPL.   Updated V5_Apr25_2020 by Dr. John Yap.   Please consider supporting OSCAR BC.

(Complete this section and sign below ONLY if patient has no MSP coverage)
(Signature Required)
Subject:
Creative Commons License created February 12 2016 by Dr. John Robertson, licensed under a GPL.   Updated V6_May24_2020 by Dr. John Yap.   Please consider supporting OSCAR BC.