Application For Enrolment - British Columbia Health Insurance Bc
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1
2MEDICAL SERVICES PLAN (MSP)
APPLICATION FOR ENROLMENT
PLEASE PRINT IN CAPITAL LETTERS ONLY
1 2 3 4 A B C D
This form may also be completed and submitted online at
To complete MSP enrolment, adult Canadian Citizens and Permanent Residents must obtain a Photo BC Services Card by visiting an Insurance Corporation of BC
(ICBC) driver licensing office. To find an ICBC driver licensing office near you, please visit
Residents of BC are required, by law, to enrol themselves and to enrol their spouse and children who are residents of BC.
RESIDENT means a person who is a citizen of Canada or is lawfully admitted to Canada for permanent residence, who makes his or her home in British Columbia, and is
physically present in British Columbia for at least 6 months in a calendar year, or a shorter prescribed period, 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.
1 APPLICANT INFORMATION
APPLICANT LEGAL LAST NAME
APPLICANT LEGAL FIRST NAME
APPLICANT LEGAL SECOND NAME
BIRTHDATE (MM / DD/ YYYY)
GENDER
DAYTIME TELEPHONE NUMBER
As a person must be a resident of BC to qualify for provincial health care benefits,
M
your current residential address is required.
F
RESIDENTIAL ADDRESS
CITY
PROV
POSTAL CODE
MAILING ADDRESS (IF DIFFERENT FROM RESIDENTIAL ADDRESS)
CITY
PROV
POSTAL CODE
2 RESIDENCE AND CITIZENSHIP / IMMIGRATION INFORMATION
STATUS IN CANADA - PROVIDE PHOTOCOPIES OF ALL APPLICABLE DOCUMENTS (DO NOT SEND ORIGINALS)
A
CANADIAN CITIZEN – Canadian Birth Certificate,
HOLDER OF PERMANENT RESIDENT STATUS – Record of Landing, Permanent
OTHER – Work or Study Permit, etc.
Canadian Citizenship Card or Passport
Resident Card (front & back) or Confirmation of Permanent Residence
PERSONAL HEALTH NUMBER (PHN)
HAVE YOU HAD MSP COVERAGE PREVIOUSLY?
B
→
IF YES, PROVIDE
YES
NO (IF NO, GO TO “C”)
(MM / DD / YYYY)
(MM / DD / YYYY)
→
MOST RECENT MOVE TO CANADA
→
MOST RECENT MOVE TO BC
(IF WITHIN PAST 12 MONTHS)
HAVE YOU LIVED IN BC SINCE BIRTH?
C
PROVINCE OR COUNTRY MOVED FROM
PREVIOUS HEALTH NUMBER
YES
NO (IF YES, GO TO “D”)
IS THIS A PERMANENT MOVE?
YES
NO
HAVE YOU OR ANY FAMILY MEMBER BEEN OUTSIDE BC FOR MORE THAN 30 DAYS IN TOTAL DURING THE PAST 12 MONTHS?
YES
NO (IF NO, GO TO “E”)
D
DEPARTURE DATE (MM / DD / YYYY)
RETURN DATE (MM / DD / YYYY)
FAMILY MEMBER NAME, REASON FOR DEPARTURE AND LOCATION
WILL YOU OR ANY FAMILY MEMBER BE AWAY FROM BC
IF ANYONE LISTED IS AN ACTIVE MEMBER OF, OR HAS BEEN RELEASED FROM, THE CANADIAN FORCES,
FOR MORE THAN 30 DAYS IN TOTAL IN THE NEXT SIX MONTHS?
YES
NO
RCMP OR AN INSTITUTION, PLEASE PROVIDE THE DISCHARGE DATE:
IF YES, SEE RESIDENCY, PAGE 2.
(MM / DD / YYYY)
E
ARE YOU A FULL-TIME STUDENT?
YES
NO
IF YES, WILL YOU RESIDE IN BC ON COMPLETION OF YOUR STUDIES?
YES
NO
3 SPOUSE AND CHILD INFORMATION
SPOUSE means a resident of BC who is either married to or living and cohabiting in a marriage-like relationship with the applicant and may be of the same gender as the applicant.
CHILD means a BC resident 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, does not have a spouse, and is supported by
the beneficiary.
PHOTOCOPIES OF CURRENT CITIZENSHIP/IMMIGRATION DOCUMENTS MUST BE ATTACHED. USE LEGAL NAMES WHEN COMPLETING THIS FORM.
SPOUSE LEGAL LAST NAME
SPOUSE LEGAL FIRST NAME
SPOUSE LEGAL SECOND NAME
GENDER
M
F
BIRTHDATE (MM / DD/ YYYY)
STATUS IN CANADA
CANADIAN CITIZEN – Canadian Birth Certificate,
HOLDER OF PERMANENT RESIDENT STATUS – Record of Landing, Permanent
OTHER – Work or
Canadian Citizenship Card or Passport
Resident Card (front & back) or Confirmation of Permanent Residence
Study Permit, etc.
PERSONAL HEALTH NUMBER (PHN)
HAS SPOUSE LIVED IN BC SINCE BIRTH?
MM / DD / YYYY
FROM (PROVINCE OR COUNTRY)
PREVIOUS HEALTH NUMBER
IF NO, MOST RECENT
YES
→
NO
MOVE TO BC
CHILD LEGAL LAST NAME
CHILD LEGAL FIRST NAME
CHILD LEGAL SECOND NAME
GENDER
M
F
BIRTHDATE (MM / DD/ YYYY)
STATUS IN CANADA
CANADIAN CITIZEN – Canadian Birth Certificate,
HOLDER OF PERMANENT RESIDENT STATUS – Record of Landing, Permanent
OTHER – Work or
Canadian Citizenship Card or Passport
Resident Card (front & back) or Confirmation of Permanent Residence
Study Permit, etc.
PERSONAL HEALTH NUMBER (PHN)
HAS CHILD LIVED IN BC SINCE BIRTH?
MM / DD / YYYY
FROM (PROVINCE OR COUNTRY)
PREVIOUS HEALTH NUMBER
IF NO, MOST RECENT
YES
→
MOVE TO BC
NO
Mailing Address: Health Insurance BC, Medical Services Plan, PO Box 9678 Stn Prov Govt, Victoria BC V8W 9P7
Tel: (Lower Mainland) 604 683-7151, (Rest of BC) 1 800 663-7100 Web:
HLTH 102 V5 Rev. 2017/11/29
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