Application For Enrolment - British Columbia Health Insurance Bc Page 2
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23 SPOUSE AND CHILD INFORMATION continued
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
YES
IF NO, MOST RECENT
→
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
YES
IF NO, MOST RECENT
→
NO
MOVE TO BC
IF YOU HAVE MORE CHILDREN, PLEASE CHECK BOX, ATTACH ADDITIONAL SHEET AND PROVIDE ALL INFORMATION
IF ANY OF THE CHILDREN ARE DEPENDENT POST-SECONDARY STUDENTS (SEE BELOW), PLEASE COMPLETE THE SECTION BELOW.
STUDENT LEGAL LAST NAME
STUDENT LEGAL FIRST NAME
STUDENT LEGAL SECOND NAME
DATE STUDIES WILL
IF SCHOOL IS OUTSIDE BC, ORIGINAL
SCHOOL NAME AND FULL ADDRESS
BE FINISHED (MM / DD / YYYY)
DEPARTURE DATE (MM / DD / YYYY)
TO ADD MORE DEPENDENT POST-SECONDARY STUDENTS, PLEASE CHECK BOX, ATTACH ADDITIONAL SHEET AND PROVIDE ALL INFORMATION
DEPENDENT POST-SECONDARY STUDENT means a BC resident who is older than 18 and younger than 25 years of age, in full-time attendance at a recognized post-secondary institution, and supported by a
parent or person who stands in place of the person’s parent. A dependent post-secondary student may include a student enrolled in full-time studies at an accredited trade school, technical school or high school.
4 PREMIUMS
Revenue Services of British Columbia issues invoices for MSP premiums on a monthly basis. Information about premium rates and subsidies can be found on Health Insurance
BC’s website at
or on the
Application for Regular Premium Assistance, HLTH
119. PLEASE DO NOT SEND PAYMENT WITH THIS APPLICATION.
5 AUTHORIZATION - MUST BE SIGNED BY APPLICANT, AND SPOUSE IF APPLICABLE (DO NOT CHANGE TEXT OF AUTHORIZATION BELOW)
I have received information about MSP and agree to abide by the terms and conditions of MSP. I understand that if a discrepancy exists between the information provided
and the legislation, the legislation will govern. I understand that the information I have given is collected under the authority of the Medicare Protection Act and section 26(a)
and (c) of the Freedom of Information and Protection Act (FIPPA) and the information will be used to assess eligibility for, and to administer, MSP and other Ministry of Health
publicly funded health care programs.
I authorize the Ministry of Health to collect my health information from practitioners who provide publicly funded health care service(s) to me under MSP and other publicly
funded health care programs, and I provide consent for those practitioners to disclose such information to the Ministry of Health for the purposes of assessing eligibility for,
and in regard to the administration of, MSP and other Ministry of Health publicly funded health care programs.
I understand that information may be disclosed by the Ministry of Health pursuant to section 33 of FIPPA.
I declare that all information provided is true and I understand that the Ministry of Health 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.
If you have any questions about the collection and use of your personal information, please contact: Health Insurance BC Chief Privacy Office, PO Box 9035 STN PROV GOVT,
Victoria, BC V8W 9E3 or call 604 683-7151 (Vancouver) or 1 800 663-7100 (toll-free).
SIGNATURE OF APPLICANT
SIGNATURE OF SPOUSE
DATE SIGNED (MM / DD / YYYY)
6 IMPORTANT INFORMATION
• IDENTIFICATION: You must send with your application: photocopies of documents that support the name and Canadian citizenship or immigration status for all persons listed.
Eligibility cannot be determined without this documentation. 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 status in the USA. If any person is not enrolling under the name shown on his/her citizenship or
immigration document, please also submit a photocopy of a legal document (for example, a marriage or name change certificate) that indicates the name shown on this application.
• RESIDENCY: If you expect to leave the province for more than 30 days in total during the next 6 months, a letter outlining your planned dates of departure and return, destination and
the reason for your absence is required with this application. Failure to provide this information may affect eligibility for benefits.
• EFFECTIVE DATE OF BENEFITS: New and returning residents must complete a wait period before health care benefits begin. Generally, this period is the balance of the month of arrival
in BC, plus two months. If absences from Canada exceed a total of 30 days during the wait period, eligibility may be affected. Applications should be submitted immediately on arrival in
BC, not at the end of the wait period. If you apply late, the effective date of benefits will be determined by MSP and may result in premiums being charged retroactively.
• OUT-OF-PROVINCE STUDENTS: Residents who leave BC temporarily to attend school or university may be eligible for MSP coverage for the duration of studies, provided they are in
full-time attendance at a recognized educational facility.
• CANCELLATION OF BENEFITS: Failure to remit premiums does not constitute notification to cancel benefits. If you will no longer be a resident of BC, you must notify Health Insurance
BC that this is the case, and provide your date of departure from the province and your new address; otherwise, premium invoicing may continue.
• CHANGE OF NAME OR ADDRESS: Health Insurance BC must be notified immediately of any change of name or address.
• LEGISLATION: All information is subject to change in accordance with the Medicare Protection Act and Regulations and the Hospital Insurance Act and Regulations.
If a discrepancy exists between the information Health Insurance BC has provided on this application and the legislation, the legislation will prevail.
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 Health Insurance BC at the address or telephone numbers on page 1. 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.
HLTH 102 PAGE 2
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