Fillable Health Canada ng Prior Approval Form Mental Health (Government of Canada)

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Health Canada ng Prior Approval Form Mental Health (Government of Canada)

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PROTECTED WHEN COMPLETED - B
First Nations and Inuit Health Br
anch
Non
-Insur
ed Health
Benefits
(NIHB)
Program
Indian Residential Schools Resolution Health Support Program (IRS RHSP)
Health Canada
Mental Health Counselli
ng Prior Approval Form
Complete this form to apply for prior approval before commencing counselling funded through either the Non-Insured Health Benefits
Program (NIHB) or the Indian Residential Schools Resolution Health Support Program (IRS RHSP). Please note that the initial client
assessment*(maximum of two hours) does not require prior approval. Counselling services must be provided in accordance with the
terms and conditions in the Guide to Mental Health Counselling Services – NIHB and IRS RHSP (”Guide”) and counselling should start
within 10 business days following the prior approval.
*In order to be eligible for payment you must be currently enrolled as a provider under either the NIHB Program or the IRS RHSP prior
to providing any services to clients. Incomplete forms will be returned unprocessed.
This form is to request (check one):
Non-Insured Health Benefits
Mental Health Counselling
Complete Sections A, B, D & E
Original request
Application for extension
Indian Residential Schools
Resolution Health Support Program
Complete Sections A, C, D, & E
Original request
Application for extension
SECTION A – Client and Provider Information (please print)
Client Information
Name of Client:
Date of Birth (YYYY/MM/DD):
Address (number and street name):
City:
Province/Territory:
Phone Number:
NIHB Eligibility (Indian Status Number for First Nations,
“N” Number or Health Care Plan Number for Inuit Clients in
living in Northwest Territories and Nunavut):
IRS RHSP Eligibility – IRSAS Verification Number:
(To be filled by Health Canada Regional Office)
Provider Information
Name of Counsellor:
Health Canada Provider Number:
Phone Number:
SECTION B – NIHB Mental Health Counselling Benefits
1. Is the client in significant distress and showing signs of being in a mental health crisis in accordance with the criteria in the Guide?
YES NO
2. Is crisis counselling available for this client from any other service/program?
YES, I will immediately refer the client to the other service NO
(Health Canada use)
Region: PA #: Date:
Postal Code:
Extension Number:
Mental Health Counselling Prior Approval Form
2
3. Is this the first time you have provided counselling to this client?
YES
NO (select) Request for an extension of counselling previously approved under the NIHB Program
Counselling relating to another crisis under the NIHB Program on: Date
Counselling relating to another mental health issue not funded by NIHB
4. Can the crisis be addressed and client transitioned to other mental health support services (if required) within 15 hours in 20
weeks?
YES NO, I have developed an aftercare plan to link the client to other services for longer term counselling
5. If services will be required after this counselling is completed, have you identified community-based or other local mental health and
culturally competent services for referral?
YES NO (please describe why not)
SECTION C – Indian Residential Schools Resolution Health Support Program
The client is a:
Former Indian Residential Student
Family Member of a Former Indian Residential School Student
Note: If the client is a family member, please provide the full name and the date of birth of the former student.
Name of former student: Date of Birth (YYYY/MM/DD):
Indian Residential School:
Years Attended (from – to):
SECTION D - Proposed Hours of Counselling
An hour of counselling is defined as fifty (50) minutes for counselling and ten (10) minutes for preparation.
Planned start date (YYYY/MM/DD): Initial assessment date (YYYY/MM/DD):
Complete for an extension of benefits:
Please note that requests for the extension of NIHB counselling hours over 15, or IRS RHSP counselling hours over 20, must be
submitted in a new Prior Approval Form following completion of treatment approved on the initial prior approval form.
1. Please explain briefly why additional hours are required:
There is a delay for the client to access provincial/territorial or community-based mental health services
The client’s condition is not yet stabilized
Other – Please specify:
Number of
Hours
Frequency Hourly Rate
Face-to-face: individual counselling family counselling
Telehealth
Group counselling (nature of the group):____________________________
Are participants to this group funded by another program? Yes No
Total number of hours requested
• NIHB – (15 hours over 20 weeks plus possibility of 5 hours extension)
• IRS RHSP – (20 hours per prior approval over a one year period)
0
Mental Health Counselling Prior Approval Form
3
2. As per Program requirements, I have referred this client to provincial/territorial mental health services or community-based services
on:
Date (YYYY/MM/DD): Expected start date (YYYY/MM/DD):
SECTION E – Acknowledgements
Client Acknowledgment:
• I contacted (provider name) _____________________________________ in order to access mental health counselling;
• I have been assessed by this counsellor and he/she has discussed the details of my assessment and the recommended
counselling hours / schedule with me;
• I confirm that my information in this form is correct, and I understand that it will be used by Health Canada’s NIHB Program and
IRS RHSP for Program administration purposes including prior approval of counselling, claims processing and administrative audit;
• My counsellor has explained to me and I understand the terms and conditions of the benefits provided under the NIHB Program or
the IRS RHSP;
• My mental health counsellor has discussed with me alternatives for transition to other mental health services (provincial, territorial
or community based) when applicable;
• I am aware that I can make a complaint to my counsellor’s regulatory body if I have concerns regarding my counsellor’s conduct
and/or practice; and
• I shall inform my provider if any changes occur in my address or general contact information.
Signature of client (or parent/guardian): Date (YYYY/MM/DD):
If parent/guardian is signing, please print your name:
Provider Acknowledgement:
• I have completed an assessment process with this client.
• I have developed a written treatment plan in partnership with my client. Together we have outlined the goals and objectives to be
worked on during our hours of counselling.
• I have informed the IRS RHSP client that he/she is also eligible to access the services of a Resolution Health Support Worker
and/or a Cultural Support Worker should he/she desire to do so.
• If at any time during treatment it becomes apparent that my client may require more than short term counselling, I will immediately
begin a process to transition him/her to longer term mental health counselling services (provincial, territorial, or community based)
in a timely fashion;
• I will make every effort to transition this client to other mental health services (provincial, territorial, or community based) that would
follow this counselling;
• I understand the terms and conditions of the NIHB Program and/or IRS RHSP;
• I have explained the terms and conditions of the applicable Program to the client, and he/she has acknowledged understanding
them;
• I will submit claims for services to either the NIHB Program OR the IRS RHSP;
• I will not charge any fees to the client for services provided;
• I will not charge any fees to NIHB or IRS RHSP for report writing;
• I will only submit claims in accordance with the Guide;
• I will co-operate with Health Canada administrative audit activity and provide any requested supporting documentation to Health
Canada, if required; and
• I will update client contact information if any changes occur.
Signature of Provider:
Date (YYYY/MM/DD):
Privacy Notice:
The personal information you provide to Health Canada is governed in accordance with the Privacy Act. We only collect the information
needed to administer the NIHB Program and IRS RHSP. Collection of information for this purpose is authorized under the Department
of Health Act. We require this information for the adjudication and payment of claims and for audit purposes. Your personal information
may be disclosed without your consent, but only in accordance with subsection 8(2) of the Privacy Act. For more information: This
personal information collection is described in Info Source, available online at infosource.gc.ca. Personal Information Banks (PIB) for
IRS RHSP and the NIHB Program are in development. In addition to protecting your personal information, the Privacy Act gives you the
right to request access to and correction of your personal information. For more information, please contact Health Canada / Public
Health Agency of Canada’s ATIP Coordinator at 613-954-9165. You also have the right to file a complaint with the Privacy
Commissioner of Canada if you think your personal information has been handled improperly.
Mental Health Counselling Prior Approval Form
4
NIHB REGIONAL OFFICES
IRS RHSP REGIONAL OFFICES
Atlantic Region (PEI, NS, NB, NL)
Non-Insured Health Benefits
Health Canada
1505 Barrington Street, Suite 1525
Halifax, NS, B3J 3Y6
Telephone (toll-free): 1-800-565-3294
Fax (toll-free): 1-866-963-7700
Atlantic Region (PEI, NS, NB, NL)
Indian Residential Schools – Resolution Health Support Program
First Nations and Inuit Health Branch
Health Canada
1505 Barrington Street, Suite 1525
Halifax, NS, B3J 3Y6
Telephone (toll-free): 1-866-414-8111
Fax: 902-426-6158
Quebec Region
Non-Insured Health Benefits
Health Canada
202- 200 René-Lévesque Boulevard W, East Tower
Montreal, QC, H2Z 1X4
Telephone (toll-free): 1-877-483-1575
Fax (toll-free): 1-855-244-4470
Quebec Region
Indian Residential Schools – Resolution Health Support Program
First Nations and Inuit Health Branch
Health Canada
200 René-Lévesque Boulevard W, East Tower, 2nd Floor
Montreal, QC, H2Z 1X4
Telephone (toll-free): 1-877-583-2965
Fax: 514-283-8067
Ontario Region
Non-Insured Health Benefits
Health Canada
2720 Riverside Drive, AL 6604E
Ottawa, ON, K1A 0K9
Telephone (toll-free): 1-800-881-3921
Fax: 1-800-806-6662
Ontario Region
Indian Residential Schools – Resolution Health Support Program
First Nations and Inuit Health Branch
Health Canada
2720 Riverside Drive, 4
th
Floor, AL 6604D
Ottawa, ON, K1A 0K9
Telephone (toll-free): 1-888-301-6426
Fax: 1-877-430-3306
Manitoba Region
Non-Insured Health Benefits
Health Canada
391 York Avenue, Suite 300
Winnipeg, MB, R3C 4W1
Telephone (toll-free): 1-800-665-8507
Fax: 204-983-2160
Manitoba Region
Indian Residential Schools – Resolution Health Support Program
First Nations and Inuit Health Branch
Health Canada
391 York Avenue, Suite 300
Winnipeg, MB, R3C 4W1
Telephone (toll-free): 1-866-818-3505
Fax: 204-983-5740
Saskatchewan Region
Non-Insured Health Benefits
Health Canada
1st Floor, South Broad Plaza
2045 Broad Street
Regina, SK, S4P 3T7
Telephone (toll-free): 1-866-885-3933
Fax: 306-780-3878
Saskatchewan Region
Indian Residential Schools – Resolution Health Support Program
First Nations and Inuit Health Branch
Health Canada
2045 Broad Street, 5th Floor
Regina, SK, S4P 3T7
Telephone (toll-free): 1-866-250-1529
Fax: 306-780-5965
Alberta Region
Non-Insured Health Benefits
Health Canada
9700 Jasper Avenue, Suite 730
Edmonton, AB, T5J 4C3
Telephone (toll-free): 1-800-232-7301
Fax: 780-495-3184
Alberta Region
Indian Residential Schools – Resolution Health Support Program
First Nations and Inuit Health Branch
Health Canada
9700 Jasper Avenue, Suite 730
Edmonton, AB, T5J 4C3
Telephone (toll-free): 1-888-495-6588
Fax: 780-495-3184
Northern Region (YT)
Non-Insured Health Benefits
Health Canada
300 Main Street, Suite 100
Whitehorse, YT, Y1A 2B5
Telephone (toll-free): 1-866-362-6717
Fax: 1-867-667-3999
Northern Region (YT, NT, NU)
Indian Residential Schools – Resolution Health Support Program
First Nations and Inuit Health Branch
Health Canada
300 Main Street, Suite 100
Whitehorse, YT, Y1A 2B5
Telephone (toll-free): 1-800-464-8106
Fax: 867-667-3999
First Nations Health Authority
Federal Building
757 West Hastings Street, Suite 540
Vancouver, BC, V6C 3E6
Telephone (toll-free): 1-877-477-0775
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Health Canada ng Prior Approval Form Mental Health (Government of Canada)

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Completed 11 December 2020

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