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NS ESIA Request for Essential Medical Treatment

Nova Scotia's Employment Support and Income Assistance (ESIA) program uses this form when a health practitioner prescribes a medical treatment that MSI and other government programs do not cover, such as massage therapy, acupuncture, chiropractic or periodontal care. Under Policy 8.2.20, the request must show a diagnosed condition, the alternatives tried or considered, the costs, and medical evidence that the treatment is necessary and effective.

Who completes it

The prescribing health practitioner, who must be licensed to practise in Nova Scotia as a physician, dentist or nurse practitioner, completes the form. The treatment itself must be provided by a medical professional licensed or registered to practise in Nova Scotia.

Submitting and payment

How to submit it
The request goes through the client's ESIA caseworker, and approval must come first: the manual allows special needs to be approved after purchase only in emergencies.
Who pays
The policy manual sets no fee for completing the request; if approved, ESIA funds the treatment as a special need, with approval authority rising with cost up to the Director, Income Assistance.

Good to know

  • All four criteria must be met: a qualifying prescriber, a provider licensed or registered in Nova Scotia, a completed request form, and the treatment being the most economical option.
  • The form must describe the alternatives through MSI, private insurance, funded organizations or government that were attempted or considered, and why they did not address the condition.
  • Insured services and prescription drugs are excluded; the special needs schedule gives physiotherapy and speech therapy as examples of insured or government-provided treatments ESIA cannot approve.
  • Before deciding, the caseworker may ask for a second medical opinion from someone qualified to judge whether the request meets the essential medical treatment criteria.

Get the official form

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

Request for Essential Medical Treatment

Official page

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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 ESIA Request for Essential Medical Treatment?

Only a health practitioner licensed to practise in Nova Scotia as a physician, dentist or nurse practitioner can prescribe the item or service and complete the form. The treatment must then be delivered by a medical professional who is licensed or registered to practise in Nova Scotia.

What treatments can ESIA fund as essential medical treatment?

Policy 8.2.20 covers treatments prescribed for medical purposes that are not covered by MSI or otherwise funded by government, such as massage therapy, acupuncture, chiropractic and periodontal care. The evidence must show a properly diagnosed condition and a treatment that is appropriate, effective and available at reasonable cost.

What costs does the request need to show?

The practitioner gives the cost of the recommended treatment and of the alternatives considered, if known. Approval authority for special needs rises with cost: caseworkers, casework supervisors and specialists approve progressively larger amounts, and the largest requests go to the Director, Income Assistance.