Form Hr3320 PDF Details

In today's interconnected world, accessing essential medical care for those located far from specialist services can be a significant challenge, particularly for individuals facing financial constraints or those with disabilities. Understanding the pathways to secure support for such critical trips is vital. Among these, the HR3320 form represents a critical piece of documentation for residents of British Columbia seeking financial assistance for non-local medical transportation. This form is designed under the auspices of the Employment and Assistance Act and the Employment and Assistance for Persons with Disabilities Act, providing a structured process for individuals to request aid. It meticulously collects personal and medical appointment details to ascertain eligibility and the necessity of travel support. Furthermore, it includes provisions for medical escorts, should the patient's condition require it, thereby ensuring safety and assistance en route to receiving care. Accommodation and travel specifics, including modes of transportation and potential costs contributions, are also covered, underscoring the form's comprehensive nature in addressing the logistical aspects of accessing medical treatment. The HR3320 form thus not only serves as a request document but also as a guide to navigating the broader framework of support available through programs like the Travel Assistance Program (TAP), aimed at alleviating the financial burden on individuals in need of accessing essential health services beyond their local community.

QuestionAnswer
Form NameForm Hr3320
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesrequest for local and non local medical transportation, medical transportation form, request for local or non local medical transportatiom assistance, request for local or non local medical transportation msdpr

Form Preview Example

REQUEST FOR NON-LOCAL MEDICAL TRANSPORTATION ASSISTANCE

CASE NUMBER

SR NUMBER

The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Employment and Assistance Act and the Employment and Assistance for Persons with Disabilities Act. The collection, use and disclosure of personal information is subject to the provisions of the Freedom of Information and Protection of Privacy Act. Any questions about this information should be directed to the ministry.

Please complete this form and, if possible, return it to our office a minimum of 7 business days before your date of appointment.

PART 1 - PATIENT INFORMATION

APPLICANT

LAST NAME

FIRST NAME

TELEPHONE

 

 

 

 

PATIENT

LAST NAME

FIRST NAME

TELEPHONE

 

 

 

 

 

 

 

PART 2 - MEDICAL APPOINTMENT INFORMATION

 

 

APPOINTMENT DETAILS (INCLUDE DATE, TIME AND LOCATION FOR ALL RELATED APPOINTMENTS)

 

 

 

 

SPECIALIST/HOSPITAL/SPECIALTY CLINIC NAME

 

TELEPHONE

 

 

 

REFERRING MEDICAL/NURSE PRACTITIONER

 

TELEPHONE

 

 

 

 

Medically required escorts must be validated with a written note/letter from physician or identified on the Travel Assistance Program (TAP) form. For more information on TAP, visit http://www.health.gov.bc.ca/tapbc/tap_patient.html.

MEDICAL ESCORT REQUIRED

 

TYPE OF VALIDATION PROVIDED

 

 

TAP CONFIRMATION #

 

 

Yes

No

 

Physician Note

TAP Form completed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART 3 - TRAVEL INFORMATION

 

 

 

 

 

 

Travel Details

 

 

 

 

 

 

 

 

 

 

 

DEPARTURE DATE

 

 

 

RETURN DATE

 

 

 

 

LOCATION YOU ARE TRAVELLING FROM

 

 

 

 

 

 

 

 

 

 

 

 

Are you able to contribute to the cost of this medical transportation?

Yes

No

If yes, how much?

 

 

 

 

 

 

 

 

 

If no, have you considered the following options to assist with your medical transportation cost?

Family/Friends

Yes

 

 

No

Volunteer Agencies

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accommodation

 

 

 

 

 

 

 

 

 

 

 

Do you require overnight accommodation?

If Yes, please identify which accommodation:

 

 

 

Yes

 

 

No

 

 

 

Family/Friends

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have accommodation arrangements already been made/booked? If so, provide details:

 

 

Are any special needs arrangements necessary? (EG: Wheelchair accesible room, etc.) If so, provide details:

 

 

 

 

 

Method of Payment

 

Direct Deposit

Cheque Mailed

Cheque Pick Up in Office

 

 

 

 

 

 

 

 

 

 

 

 

Transportation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

What mode of transportation will you require?

Personal Vehicle

Air

Bus

PREFERRED DEPARTURE DATES AND TIMES (BUS TRAVEL ONLY)

NAME OF BUS COMPANY (IF REQUIRED)

PART 4 - DECLARATION (please read and sign)

I declare that all information I have provided is true and complete. I understand that the accuracy of the information I provide may be checked by comparing it against information held by other governments, public bodies, private agencies and individuals. The BC government may verify and obtain information to confirm my eligibility or the eligibility of my dependents.

 

APPLICANT SIGNATURE

 

 

DATE SIGNED

 

 

 

 

 

 

 

 

HR3320 (15/07/13)

Security Classification: MEDIUM SENSITIVITY

 

Page 1 of 1

 

 

 

MEDICAL TRANSPORTATION

INFORMATION CHECKLIST - FOR CLIENTS

Under the BC Employment and Assistance Program, a medical transportation supplement can be provided for persons facing extraordinary travel costs associated with essential medical treatment. This supplement is available when no other financial resources are available to cover the cost.

Essential medical treatments are non-emergency, insured medical services covered by Medical Services Plan (MSP) or the Hospital Insurance Act.

The purpose of this checklist is to provide you with information on the procedures which must be followed to help determine your eligibility for a medical transportation supplement.

Local Non-Emergency Medical Transportation

If the essential medical treatment is provided locally and you require a medical transportation supplement, you must:

•Explore all options and resources (i.e. family, voluntary agencies).

•Explore all options and resources (i.e. family, voluntary agencies).

PConfirmation that the medical treatment is covered by MSP or the Hospital Insurance Act.

PNumber of appointments per week necessary for the treatment.

PExpected duration of the treatment.

PSpecify whether an escort is medically required or not required. (only eligible if accompanying a patient who is 18 years of age and under or who is incapable of travelling independently due to medical reason)

PSpecific reason why you are unable to use public transportation, if you require a taxi on an ongoing basis.

Non-Local Non-Emergency Medical Transportation

If the essential medical treatment is provided outside your home community and you require a medical transportation supplement, you must:

•Explore all options and resources (i.e. family, voluntary agencies).

•Request a written verification with the same information listed above or the Travel Assistance Program (TAP) form from your physician. TAP is a program developed by the Ministry of Health Services with participating transportation partners to provide travel assistance to eligible BC residents who are required to travel outside their home community to obtain non-emergency, physician-referred specialist medical care. For more information about the program, go to http://www.health.gov.bc.ca/msp/mtapp/tap_patient.html.

•If a TAP form is required, submit a copy of the TAP form with confirmation number.

•Please consult with your local office to determine which document (a written verification or a TAP form) is required.

•Fill out and submit a Non-Local Medical Transportation Request form (HR3320).

•If you must return to the specialist, hospital or specialty service as part of the same course of treatment, the destination specialist’s office or specialty service can complete and sign or stamp another TAP form. A new TAP form should be issued for each subsequent visit at the time the next appointment is made and a copy should be submitted to the ministry.

Your eligibility for a medical transportation supplement will be assessed once all requested information is provided and all other resources have been considered. The most affordable option will be considered.

Failure to provide the necessary information required to determine your eligibility may result in delays processing your request.

This ministry may verify the information provided and perform post audit verification to confirm that the funding was used for its intended purpose.

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It is actually straightforward to complete the pdf with our practical tutorial! Here is what you need to do:

1. For starters, when completing the non local transportation form, start with the area that includes the next fields:

Step number 1 of completing non local medical transportation form hr3320

2. Soon after this part is filled out, proceed to type in the suitable details in these: Yes, Physician Note, TAP Form completed, PART TRAVEL INFORMATION, Travel Details DEPARTURE DATE, RETURN DATE, LOCATION YOU ARE TRAVELLING FROM, Are you able to contribute to the, Yes, If yes how much, If no have you considered the, FamilyFriends, Yes, Volunteer Agencies, and Yes.

Physician Note, Travel Details DEPARTURE DATE, and PART TRAVEL INFORMATION of non local medical transportation form hr3320

In terms of Physician Note and Travel Details DEPARTURE DATE, be sure that you get them right in this section. These two could be the most significant ones in this file.

3. The following segment should be fairly uncomplicated, What mode of transportation will, Air NAME OF BUS COMPANY IF REQUIRED, PART DECLARATION please read and, APPLICANT SIGNATURE, Security Classification MEDIUM, Page of, and DATE SIGNED - every one of these empty fields has to be filled out here.

Step # 3 in filling in non local medical transportation form hr3320

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