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BC Form HR3635: Request for Diet Supplement

B.C. assistance clients take this form to a physician, nurse practitioner or registered dietitian to confirm a therapeutic diet so the ministry can pay a monthly diet supplement. Eligible diets are restricted sodium, diabetic, kidney dialysis, high protein for listed conditions, gluten-free, dysphagia, cystic fibrosis, ketogenic and low phenylalanine. The practitioner records the diagnosis, the diet and the duration of need.

Who completes it

A medical practitioner, nurse practitioner or registered dietitian completes the medical diagnosis, type of diet and duration of need (24 months maximum), then signs and stamps the form. The client completes their information and signs the consent to release medical information.

Submitting and payment

How to submit it
The ministry issues the form under a Service Request number and the client takes it to their practitioner; staff may waive new documentation when enough medical information is already on file.
Who pays
The ministry is not responsible for documentation fees, so the client pays any fee the practitioner charges to complete the form.

Good to know

  • High protein diets qualify only for listed conditions, such as cancer during treatment, chronic bacterial infection, Crohn's disease, ulcerative colitis, HIV, AIDS, hepatitis B or C, hyperthyroidism, osteoporosis or tuberculosis.
  • Policy limits duration to 12 months for acute conditions and 24 months for chronic conditions, and reviews take place at least every two years.
  • The kidney dialysis diet requires eligibility for Ministry of Health dialysis services, and the diabetic diet is only for people who have diabetes.
  • Clients already receiving another nutrition-related supplement are not eligible, and a review not completed within three months ends the supplement.

Get the official form

Download the current version from the source each time; forms change without notice.

Request For Diet Supplement

Official pagePDF

Fill it with Vero

Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.

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Frequently asked questions

Who can complete the BC Request for Diet Supplement?

A medical practitioner, nurse practitioner or registered dietitian. They record the medical diagnosis, tick the type of diet required, state the duration of need in months (24 months maximum), then sign, date and apply their office stamp.

Can a diet supplement be approved for a condition not on the list?

No. Ministry policy says a high protein supplement is available only when the diet is confirmed as necessary for one of the listed conditions, and supplements cannot be issued for conditions that are not listed, even if a practitioner confirms the need.