Fillable Msp Ride Along Request Form (Page 2 of 2) in pdf

iMpORTANT iNFORMATiON

Eligibility for provincial health care benefits is based on residency in British Columbia. Under the Medicare Protection Act, RESiDENT means a person who is a citizen

of Canada or is lawfully admitted to Canada for permanent residence, makes his or her home in British Columbia, and is physically present in British Columbia at least 6

months in a calendar year, and includes a person who is deemed under the regulations to be a resident but does not include a tourist or visitor to British Columbia.

DEpENDENT

includes a spouse and children who are residents of BC.

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SpOUSE

with respect to another person means a resident who is married to or is living and cohabiting in a marriage-like relationship with the other person and, for

—

the purposes of this definition, the marriage or marriage-like relationship may be between persons of the same gender.

CHiLD

means a person who is a child of a beneficiary or a person in respect of whom a beneficiary stands in the place of a parent and who is a minor, or, is older than

—

18 and younger than 25 years, and is in full-time attendance at an approved educational institution, is supported by the beneficiary and does not have a spouse.

DOCUMENTS REqUiRED

pHOTOCOpiES MUST bE iNCLUDED OR FORM WiLL bE RETURNED

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If you are adding new dependent(s) include with this form, photocopies of documents to show the legal name and to support Canadian citizenship or immigration status

of all those, including newborns, to be covered. This information will be used to determine eligibility for coverage and when coverage can begin.

Canadian citizens and holders of permanent resident status (landed immigrants) returning from the USA may also be asked to provide evidence of having established

residence in BC and/or having abandoned their US status.

AbSENCES

If you or any family member expect to leave the province for more than 30 days, in total, during the next 6 months, a letter outlining your planned date

—

of departure, where you will be, the reason for the absence and your expected date of return is required. If you or any family member have been outside BC for more

than 30 days during the past 12 months, a letter is required giving all dates of departure from BC, your whereabouts, the reason for each absence and all dates of

return to BC. If you or any family member spend part of each year outside the province you must reside in Canada at least 6 months in a calendar year and continue

to maintain your home in BC, to qualify for provincial health care benefits.

OUT-OF-pROViNCE STUDENTS

Residents who leave BC temporarily to attend school or university may be eligible for benefits for the duration of studies pro-

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vided they are in full-time attendance at an accredited educational facility, and are enrolled in a program that leads to a degree or certificate recognized in Canada.

YOUR ACCOUNT OR PERSONAL HEALTH NO.

C. DELETiON OF DEpENDENT(S)

BIRTHDATE

GENDER

CANCELLATION DATE

FIRST NAME

SECOND NAME

SURNAME

REASON FOR CANCELLATION

YYYY

M / F

YYYY

CURRENT MAILING ADDRESS OF DEPENDENT

FIRST NAME

SECOND NAME

SURNAME

REASON FOR CANCELLATION

YYYY

M / F

YYYY

CURRENT MAILING ADDRESS OF DEPENDENT

FIRST NAME

SECOND NAME

SURNAME

REASON FOR CANCELLATION

M / F

YYYY

CURRENT MAILING ADDRESS OF DEPENDENT

D. CHANGE OF pERSONAL iNFORMATiON

If the names or birthdate which appear on the CareCard need changing, you are asked to include a photocopy of a legal document indicating the

cardholder’s correct name or birthdate, such as one of the documents listed under B5 on the previous page or a change of name or marriage certificate.

current carecard shows

revised or correct information is

BIRTHDATE

INITIALS

SURNAME

FIRST NAME

SECOND NAME

SURNAME

YYYY

E. RESiDENTiAL AND MAiLiNG ADDRESS

ALL CHANGES OF ADDRESS MUST bE REpORTED iMMEDiATELy TO MSp

As you must be a resident of British Columbia to be eligible for provincial health care benefits, your current residential address is required on this form.

A form received without a residential address will be returned.

ACCOUNT HOLDER'S RESiDENTiAL AND MAiLiNG ADDRESS

RESIDENTIAL ADDRESS

(if different from residential address)

MAILING ADDRESS

POSTAL CODE

DAYTIME TELEPHONE NUMBER

POSTAL CODE

TELEPHONE NUMBER

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