Fillable Msp Ride Along Request Form printable pdf download

This is a fill and print form

MEDiCAL SERViCES pLAN

GROUp CHANGE FORM

Mailing Address: PO Box 9140 Stn Prov Govt, Victoria BC V8W 9E5

Tel: (Vancouver) 604 683-7520, (Other Areas Within BC) 1 877 955-5656

Fax: 250 405-3594

Web:

Residents of BC are required, by law, to enroll themselves and their dependents with the Medical Services Plan of BC.

Personal information on this form is collected under the authority of the Medicare Protection Act. The information will be used to determine residency in BC and determine eligibility for provincial health care benefits.

If you have any questions about the collection of this information, contact a Health Insurance BC client service representative at the address and telephone numbers shown above. Personal information is protected from

unauthorized use and disclosure in accordance with the Freedom of Information and Protection of Privacy Act and may be disclosed only as provided by that Act.

ACCOUNT HOLDER’S LEGAL NAME — THiS SECTiON MUST bE COMpLETED

FiRST / SECOND / SURNAME

GROUp

ACCOUNT OR pERSONAL HEALTH NO.

A. ADDiTiON / CHANGE

NEW

DEPT. /

EMPLOYEE

NO.

PAYLIST

b. ADDiTiON OF DEpENDENTS — USE LEGAL NAMES ONLy

SEE NEXT pAGE FOR DEFiNiTiON OF RESiDENT AND DEpENDENT(S)

BIRTHDATE

GENDER

REqUESTED EFFECTIVE DATE

FIRST NAME

SECOND NAME

SURNAME

PERSONAL HEALTH NUMBER

YYYY

M / F

YYYY

1. Relationship to you

Date of marriage and previous surname (if applicable)

2. If child is 19 to 24 years of age, indicate name and address of school he/she is attending on a full-time basis

enrollment date__________________ date studies will be completed ______________________.

If school is outside BC, provide original date of departure

SEE NEXT pAGE AbOUT OUT-OF-pROViNCE STUDENTS

Will dependent reside in BC upon completion of studies?

yes

3. If dependent child is newly adopted, indicate date of adoption

ENCLOSE pROOF OF ADOpTiON

4. Has spouse/child lived in BC since birth?

yes

If no, complete the following

Spouse/child’s previous place of residence

Most recent move to BC

Is this a permanent move?

yes

5. Spouse/child’s status in Canada

pHOTOCOpiES OF DOCUMENTS ARE REqUiRED FOR ALL DEpENDENTS bEiNG ADDED, iNCLUDiNG NEWbORNS. SEE NEXT pAGE.

(Canadian Birth Certificate or Canadian Citizenship Card)

CANADIAN CITIZEN

(Record of Landing, Permanent Resident Card (front & back) or Confirmation of Permanent Residence)

HOLDER OF PERMANENT RESIDENT STATUS

(Work Permit, Study Permit, etc.)

OTHER

}

6. Do you or any family member plan to be away from BC for more than 30 days during the next six months?

yes

iF yES, SEE NEXT pAGE

REGARDiNG AbSENCES

6a. Have you or any family member been outside BC for more than 30 days during the past 12 months?

yes

7. Is dependent an active member of the Canadian Armed Forces or RCMP?

yes

If dependent has recently been released from the Canadian Armed Forces, RCMP, or an institution, please provide date of discharge/release

DECLARATiON MUST bE SiGNED

MSp MUST HAVE yOUR CURRENT ADDRESS — SEE NEXT pAGE

• I have received information about MSP and agree to abide by the terms and conditions of MSP.

• I understand the information I have given is collected under the authority of the Medicare Protection Act and may be used to assess eligibility for other Ministry of Health programs.

• I understand that practitioners who provide service(s) under MSP are required under the Medicare Protection Act to release information relative to those services to MSP to

support claims for benefits.

• I declare that all information provided on this application is true and I understand that the Ministry and/or Health Insurance BC may verify this information with immigration

authorities, law enforcement authorities and other public authorities, agencies and persons as appropriate.

• I declare that all persons listed are residents of British Columbia.

YYYY

DATE

SIGNATURE OF

SIGNED

ACCOUNT HOLDER

YYYY

DATE

SIGNATURE OF

SIGNED

SPOUSE