Medical Services Plan Premium Assistance Information

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Telephone:
Vancouver 604 683-7520
Mailing Address:
Other Areas
PO Box 9140 Stn Prov Govt
Within BC
1 877 955-5656
Facsimile:
250 405-3594
Victoria BC V8W 9E5
PRINT NAME AND ADDRESS
Group
_________________________
Account
_________________________
MSP USE ONLY
ACCOUNT NUMBER
DATE RECEIVED
DOC TYPE
1PA
MEDICAL SERVICES PLAN PREMIUM ASSISTANCE INFORMATION
The Medical Services Plan (MSP) offers premium reductions ranging from 20% to 100% based on the
previous year’s income. To qualify for this assistance, the Adjusted Net Income must be $28,000 or less.
An application is on page 2.
Personal information on this form is collected under the authority of the Medicare Protection Act.
The information will be used to determine eligibility for premium assistance and may also be used to
determine entitlement to other Ministry of Health benefits, or to benefits under the Healthy Kids program.
If you have any questions about the collection of this information, contact a Health Insurance BC client
service representative at the address or 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.
Questions regarding the Healthy Kids program (limited to children age 18 and under) should be directed
to that program at 1 800 748-1144.
Who Can Apply?
Assistance is available only to persons who, for the last 12 consecutive months, have been resident in
Canada and have been a Canadian citizen or holder of permanent resident status (landed immigrant).
Income Verification
Each year, with the written consent of the applicant, MSP verifies income information with the Canada
Revenue Agency to ensure applicants are receiving the level of assistance for which they are eligible.
If required, MSP premium rates are adjusted upward or downward as of the date assistance is effective.
To ensure that verification can take place, income tax returns must be filed under the name and birth
date on record with MSP.
HOW TO APPLY:
Calculate your Adjusted Net Income using the application on the reverse.
STEP 1
STEP 2
If you qualify for assistance, read and sign the Declaration and Consent.
STEP 3
Have your employer (or pension, pay office or union welfare plan) authorize and
send your application to MSP.
GROUP AUTHORIZATION: __________________________________________________________
PAGE 1
HLTH-MSP 120 Rev. 2005/07/21

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