British Columbia Gazette Part II — B.C. Reg. 40/2002
B.C. Reg. 40/2002
British Columbia — Gazette
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Volume 45, No. 4
B.C. Reg. 40/2002
The British Columbia Gazette,
Part II
March 12, 2002
B.C. Reg. 40/2002, deposited March 1, 2002, pursuant to the
HEALTH CARE (CONSENT) AND CARE FACILITY (ADMISSION) ACT [section 1]. Order in Council 173/2002, approved and ordered March 1, 2002.
On the recommendation of the undersigned, the Lieutenant Governor, by and with the advice and consent of the Executive Council, orders that the Health Care Consent Regulation, B.C. Reg. 20/2000, is amended
(
a) in
section 2 (2) by striking out "2002" and substituting "2003,"
(
b) by repealing
section 8 (2), and
(
c) by repealing Form 1 and Form 2, and replacing them with Form 1 and Form 2 as contained in the attached schedule. — C. HANSEN, Minister of Health Services ; G. CAMPBELL, Presiding Member of the Executive Council .
Schedule
Form 1
Health Care (Consent) And Care Facility (Admission) Act
section 14 (4) (
b) of the Act
NOTICE OF INCAPABILITY AND SUBSTITUTE CONSENT
(MAJOR HEALTH CARE)
To ..............................................................................................
[ name of adult for whom substitute consent has been given (please print) ]
I, ..........................................................................................................................................
[ name of health care provider (please print) ], am your physician/other health care provider and I have proposed the following health care for you:
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
I have determined, using the legal test of incapability stated in
section 7 of the
Health Care (Consent) and Care Facility (Admission) Act , that you are incapable of giving or refusing consent to the health care described above.
To the best of my knowledge, you do not have a committee, or representative, who is authorized to make a decision for you about the health care described above.
Therefore, I have chosen ............................................................................................................
[ name and phone number of Temporary Substitute Decision Maker (please print) ] as temporary substitute decision maker for you and he/she has
given refused[ check ONE box only ] substitute consent to the health care described above.
You, your spouse or a relative or friend of yours has the right to request a review of the decision to give or refuse substitute consent for the health care described above. A request for a review must be delivered to the Health Care and Care Facility Review Board within 72 hours after the decision to give or refuse substitute consent for the health care described above was made. The request must be delivered to:
The Registrar
Health Care and Care Facility Review Board
Suite #301, 747 Fort Street
Victoria, BC V8W 3E9
Tel: 250 387-0383
Fax: 250 387-1820
The decision to give refuse[ check ONE box only ] substitute consent to health care described above was made on
.....................................................
[ dd/mm/yyyy ] at
...................................................................... [ time ] a.m./p.m.
...............................................................
[ signature of health care provider ] ................................ [ position/title ]
.............................................................................
[ dd/mm/yyyy ] ................................................... [ time ] a.m./p.m.
Form 2
Health Care (Consent) and Care Facility (Admission) Act
section 28 of the Act
REQUEST FOR REVIEW
I am requesting a review of the decision made on
.......................................................................... [ dd/mm/yyyy ] at
.................................. [ time ] a.m./p.m. by
...................................................... [ name of substitute decision
maker ]
to give refuse revoke [ check ONE boxonly ] substitute consent to the following health care:
................................................................................................................................................................................
................................................................................................................................................................................
................................................................................................................................................................................
This health care is being provided by proposed by [ check ONE boxonly ]
............................................................ [ name of health care
provider ] for ...........................................................
[ name of adult to whom health care is being provided/is proposed ].
In
summary, the reasons for requesting a review are as follows:
................................................................................................................................................................................
................................................................................................................................................................................
................................................................................................................................................................................
APPLICANT INFORMATION
......................................................................................................................................................................
[ name ]
..................................................................................................................................................................
[ address ]
...............................................................................
[ city ]
....................................................................... [ province ]
..................................... [ telephone ]
.......................................... [ fax ]
................................................ [ postal code ]
..............................................................................................
[ relationship to adult who is subject of this request ]
ADULT INFORMATION
......................................................................................................................................................................
[ name ]
..................................................................................................................................................................
[ address ]
...............................................................................
[ city ]
....................................................................... [ province ]
..................................... [ telephone ]
.......................................... [ fax ]
................................................ [ postal code ]
......................................................................................
[ facility in which adult is currently located, if applicable ]
HEALTH CARE PROVIDER INFORMATION
......................................................................................................................................................................
[ name ]
..................................................................................................................................................................
[ address ]
........................................................................................................................................
[ title/position/occupation ]
...............................................................................
[ city ]
....................................................................... [ province ]
..................................... [ telephone ]
.......................................... [ fax ]
................................................ [ postal code ]
SUBSTITUTE DECISION MAKER INFORMATION
......................................................................................................................................................................
[ name ]
..................................................................................................................................................................
[ address ]
........................................................................................................................................
[ title/position/occupation ]
...............................................................................
[ city ]
....................................................................... [ province ]
..................................... [ telephone ]
.......................................... [ fax ]
................................................ [ postal code ]
..............................................................................................
[ relationship to adult who is subject of this request ]
This request must be delivered to the board within 72 hours after the decision to be reviewed is made, or the Board May not be able to consider your request. The request must be delivered to:
The Registrar
Health Care and Care Facility Review Board
Suite #301, 747 Fort Street
Victoria, BC V8W 3E9
Tel: 250 387-0383
Fax: 250 387-1820
The Board must hold a hearing within 7 days of receiving a request for review. Please answer the following questions:
Where would you like the hearing to be held?
..........................................................................................................
Do you need a translator? yes/no [ circle one ]
Are you being represented by legal counsel? If yes, please complete the following:
...........................................................................................................................................
[ name of legal counsel ]
..................................................................................................................................................................
[ address ]
...............................................................................
[ city ]
....................................................................... [ province ]
..................................... [ telephone ]
.......................................... [ fax ]
................................................ [ postal code ]
The Board must inquire fully into the circumstances of your case. Please send the Registrar copies of all documents you intend to rely on at least 24 hours before the hearing
.......................................... [ signature of applicant ]
.......................... [ dd/mm/yyyy ] ....................... [ time ] a.m./p.m.
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