Plan members send this application to Canada Life before each gender affirmation procedure to confirm eligibility under their workplace plan. The attending clinician confirms the patient is under their care following a diagnosis of gender dysphoria, the procedure requested, provincial coverage status and medical necessity, and Canada Life writes to the member with its decision after review.
The attending physician or other qualified healthcare provider completes Part 5; in Quebec, the form notes this information is not required by law to come from a physician. The plan member completes Parts 1, 2 and 4.
Download the current version from the source each time; forms change without notice.
Gender Affirmation Procedure Application
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No. Part 5 can be completed by the attending physician or another qualified healthcare provider, and the form notes that in Quebec, by law, this information is not required to be provided by a physician. Elsewhere, the attending physician or other qualified healthcare provider completes it.
Before each procedure. The instructions ask plan members to send a Gender Affirmation Procedure Application before each gender affirmation procedure, to the Benefit Payment Office for their plan. Once Canada Life completes its review, it writes to the plan member with its decision.
Part 5 asks whether the patient has applied to their provincial or territorial plan and whether coverage is available there. If it is, the patient must apply for provincial or territorial coverage and give Canada Life the confirmation of approval or denial from the provincial plan or program.