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Medical Assistance in Dying (MAiD) Patient Request and Consent Form
2024-09-09
This consent form is required to participate in the MAiD process. Individuals are encouraged to complete the consent form in advance of their assessment with the MAiD provider. Consent can be withdrawn or cancelled at any time.
For more information, visit Medical Assistance in Dying.
Provincial Medical Assistance in Dying (MAiD) Clinic Referral and Intake Form
2024-09-09
This form is to be completed by your health care provider.
Gender Confirming Surgery Prior Approval Request Form
2024-09-09
Gender confirming surgery is insured under PEI Medicare when prior authorization has been obtained from Health PEI. Your family physician or nurse practitioner will need to complete this form and provide the necessary attachments to Health PEI's Out-of-Province Coordinator.
Provincial Renal Program Travel Package
2024-08-27
This travel package must be completed to arrange for dialysis services in PEI.
Eye See...Eye Learn Co-pay Reimbursement Application
2024-07-16
Complete and submit an application for co-pay reimbursement for the Eye See... Eye Learn program if your optometrist is unable to bill your insurance provider directly. You will have to pay up front and be reimbursed for the remaining amount.
Home Care Referral Form
2024-05-10
Complete and submit this referral form to your local Home Care office to access services. A referral can be made by yourself, your family, care provider, or family doctor. Services are provided based on assessed need for a defined period of time.
Standard Special Authorization Request Form
2024-04-02
Some medications in the PEI Pharmacare Formulary are approved on a special authorization basis only. If your physician prescribes a drug in this category, you can submit a Standard Special Authorization Request form to have a medication considered for coverage.
Erythropoietin Program Approval Form
https://www.princeedwardisland.ca/sites/default/files/forms/erythropoietin_program_approval_form.pdf
2024-04-02
Complete this form if you have been diagnosed with chronic renal failure, or are receiving kidney dialysis. You may be eligible for coverage of anemia treatment medications, which will eliminate the need for frequent blood transfusions.
Catastrophic Drug Program Application Form
2024-04-02
Complete this form to apply for coverage of medication through the Catastrophic Drug Program.
Ankylosing Spondylitis Special Authorization Request Form
2024-04-02
Special authorization request form to be completed by your physician or diagnosing specialist.