Families apply to BC's At Home Program with this 3-page form, which opens Medical Benefits for children with severe disabilities or complex health needs. The physician or nurse practitioner records diagnoses and attests to probable dependency in eating, dressing, toileting and washing, or to direct-admit or under-3 criteria. A nurse assessor then arranges an in-home assessment for most children.
The child's physician or nurse practitioner completes and signs Section A, including diagnoses, inpatient status, any direct-admit category and, for children under 3, the initialled attestations. The parent or guardian completes and signs Section B with family details and eligibility declarations.
Download the current version from the source each time; forms change without notice.
At Home Program Application
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.
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
By signing Section A, the clinician indicates they believe the child has probable dependencies in at least three of four activities of daily living: eating, dressing, toileting and washing. Alternatively, they confirm a direct-admit category or, for children under 3, initial attestations about likely severe disability, care needs and equipment needs.
Ministry staff review it and, where appropriate, a nurse assessor visits the home to assess eating, dressing, toileting and washing, possibly contacting other providers. A regional eligibility committee then decides, and the family gets a letter. Children in Nursing Support Services Direct Care or with a qualifying palliative condition receive Medical Benefits without the assessment.
No. Families in Prince Rupert and Haida Gwaii, Smithers, Terrace and Kelowna follow a separate pilot-area process for medical benefits, described on the At Home Program website. Elsewhere, the completed CF2158 goes to the local At Home Program regional office in person, by mail or by fax.