MSP for Dependents - 102fil

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medical services plan (msp

application for enrolmen

BIRTHDATE (MM / DD/ YYYY) GENDER DAYTIME TELEPHONE NUMBER

M

f

RESIDENTIAL ADDRESS CITY PROV POSTAL CODE

MAILING ADDRESS (I DIERENT ROM RESIDENTIAL ADDRESS) CITY PROV POSTAL CODE

STATUS IN CANADA -PROVIDE PHOTOCOPIES OF ALL APPLICABLE DOCUMENTS (DO NOT SEND ORIGINALS)

CANADIAN CITIZEN Canadian Birth Certifcate, HOLDER O PERMANENT RESIDENT STATUS Record o Landing, Permanent OTHER Work or Study Permit, etc.

Canadian Citizenship Card or Passport Resident Card (ront & back) or Confrmation o Permanent Residence

I have received inormation about MSP and agree to abide by the terms and conditions o MSP. I understand the inormation I have given is

collected under the authority o the Medicare Protection Actand may be used to assess eligibility or other Ministry o Health Services programand that practitioners who provide service(s) under MSP are required under the Medicare Protection Actto release inormation relative to those

services to MSP to support claims or benefts.

I declare that all inormation provided is true and I understand that the Ministry and/or Health Insurance BC may veriy this inormation with

immigration authorities, law enorcement authorities and other public authorities, agencies and persons as appropriate. I declare that all person

listed are residents o British Columbia.

SIGNATURE O APPLICANT DATE SIGNED (MM / DD / YYYY) SIGNATURE O SPOUSE

WILL YOU OR ANY fAMILY MEMBER BE AWAY fROM BCfOR MORE THAN 30 DAYS IN TOTAL IN THE NExT SIx MONTHS?

I YES, SEE residency, PAGE 2.

ARE YOU A fULL-TIME STUDENT?

I YES, WILL YOU RESIDE IN BC ON COMPLETION O YOUR STUDIES?

I ANYONE LISTED IS AN ACTIVE MEMBER O, OR HAS BEEN RELEASED ROM, THE CANADIAORCES, RCMP OR AN INSTITUTION, PLEASE PROVIDE THE DISCHARGE DATE:

(MM / DD / YYYY)

Beore completing this application, please read important information on page 2.

Residents o BC are required, by law, to enrol themselves and to enrol their spouse and children who are residents o BC.

resident means a person who is a citizen o Canada or is lawully admitted to Canada or permanent residence, who 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.

1 applicant information

2 residence and citizenship / immigration information

a

HAVE YOU HAD MSP COVERAGE PREVIOUSLY?

YES NO (I NO, GO TO c)

PERSONAL HEALTH (CARECARD) NUMBER

B

HAVE YOU LIVED IN BC SINCE BIRTH?

YES NO (I YES, GO TO d)

(MM / DD / YYYY)

MOST RECENT MOVE TO BC

(MM / DD / YYYY)

MOST RECENT MOVE TO CANADA

(I DIERENT ROM DATE O MOVE TO BC)

IS THIS A PERMANENT MOVE?

YES NO

PROVINCE OR COUNTRY MOVED ROM PREVIOUS HEALTH NUMBERc

HAVE YOU OR ANY fAMILY MEMBER BEEN OUTSIDE BC fOR MORE THAN 30 DAYS IN TOTAL DURING THE PAST 12 MONTHS? YES NO (I NO, GO TO e)

RETURN DATE (MM / DD / YYYY)DEPARTURE DATE (MM / DD / YYYY) AMILY MEMBER NAME, REASON OR DEPARTURE AND LOCATIONd

4 aUthorization - mUst Be signed (do not change text of aUthorization Below)

e

3 premiUms

yu b b u b ru s B cub u u qu 100% u . Inormation about

premium rates and subsidies can be ound on Health Insurance BCs website at www.hibc.gov.bc.ca or on theApplication for Regular Premium Assistance, HLTH 1

please do not send payment with this application.

APPLICANT LEGAL LAST NAME APPLICANT LEGAL IRST NAME APPLICANT LEGAL SECOND NAME

PLEASE PRINT IN CAPITAL LETTERS ON

1 2 3 4 A B C D

YES NO

YES NO

YES NO

IS THIS APPLICATION ALSO FOR A SPOUSE OR CHILD? IF yES, PLEASE COMPLETE PAgE 2.

Mailing Address: Health Insurance BC, Medical Services Plan, PO Bo 9678 Stn Prov Govt, Victoria BC V8W 9P7Tel: (Lower Mainland) 604 683-7151, (Rest o BC) 1 800 663-7100 Web: www.hibc.gov.bc.ca

As a person must be a resident o BC to qualiy or provincial health care benefts,

your current address is required.

I YES, PROVIDE

DATE SIGNED (MM / DD / YYYY)

HLTH 102 V1 Rev. 2009/07

PRINT RESET
https://www.health.gov.bc.ca/exforms/msp/premium_assistance.htmlhttps://www.health.gov.bc.ca/exforms/msp/premium_assistance.html

7/27/2019 MSP for Dependents - 102fil

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SCHOOL NAME AND ULL ADDRESS I SCHOOL IS OUTSIDE BC, ORIGIN

DEPARTURE DATE (MM / DD / YYY

identification: You must send with your application: photocopies o documents that support the name and Canadian citizenship or immigration status or all persons listed.

Eligibility cannot be determined without this documentation. Canadian citizens and holders o permanent resident status (landed immigrants) returning rom the USA may also be asked to

provide evidence o having established residence in BC and/or having abandoned their status in the USA.

I any person is not enrolling under the name shown on his/her citizenship or immigration document, please also submit a photocopy o a legal document (or example, a marriage or

name change certifcate) that indicates the name shown on this application.

residency: I you expect to leave the province or more than 30 days in total during the next 6 months, a letter outlining your planned dates o departure and return, destination an

the reason or your absence is required with this application. ailure to provide this inormation may aect eligibility or benefts.

effective date of Benefits: New and returning residents must complete a waiting period beore health care benefts begin. Generally, this period is the balance o the month o

arrival in BC, plus two months. I absences rom Canada exceed a total o 30 days during the waiting period, eligibility may be aected. Applications should be submitted immediatel

on arrival in BC, not at the end o the waiting period. I you apply late, the eective date o benefts will be determined by MSP and may result in premiums being charged retroactively.

oUt-of-province stUdents: I studying outside BC, the absence must be temporary and solely or the purpose o attending ull-time studies at an accredited educational acility

a program which leads to a degree or certifcate recognized in Canada.

cancellation of Benefits: ailure to remit premiums does not constitute notifcation to cancel benefts. I you will no longer be a resident o BC, you must notiy Health

Insurance BC that this is the case, and provide your date o departure rom the province and your new address; otherwise, premium invoicing may continue.

change of name or address: Health Insurance BC must be notifed immediately o any change o name or address.

legislation: All inormation is subject to change in accordance with the Medicare Protection Actand Regulations and the Hospital Insurance Actand Regulations.

I a discrepancy exists between the inormation Health Insurance BC has provided on this application and the legislation, the legislation will prevail.

6 important information

SPOUSE LEGAL LAST NAME SPOUSE LEGAL IRST NAME SPOUSE LEGAL SECOND NAME GEND

PERSONAL HEALTH (CARECARD) NUMBER HAS SPOUSE LIVED IN BC SINCE BIRTH? MM / DD / YYYY ROM (PROVINCE OR COUNTRY) PREVIOUS HEALTH NUMBER

M

f

if yoU have more children, please checK Box, attach additional sheet and provide all information

IF ANy OF THE CHILDREN ARE 19 TO 24 yEARS OF AgE AND ATTENDINg SCHOOL ON A FULL-TIME BASIS, PLEASE COMPLETE THE SECTION BELOw.

5 spoUse and child informationspoUse means a resident o BC who is either married to or living and cohabiting in a marriage-like relationship with the applicant and may be o the same gender as the applicant.

child means a resident o BC who is the legal ward or child o the applicant, is supported by the applicant, is neither married nor living and cohabiting in a marriage-like relationship,

is either age 18 or younger, age 19 to 24 and attending school or university ull time.

PHOTOCOPIES OF CURRENT CITIzENSHIP/IMMIgRATION DOCUMENTS MUST BE ATTACHED. USE LEgAL NAMES wHEN COMPLETINg THIS FORM.

I NO, MOST RECENTMOVE TO BCYESNO

BIRTHDATE (MM / DD/ YYYY) STATUS IN CANADA

CANADIAN CITIZEN Canadian Birth Certifcate, HOLDER O PERMANENT RESIDENT STATUS Record o Landing, Permanent OTHER Work or

Canadian Citizenship Card or Passport Resident Card (ront & back) or Confrmation o Permanent Residence Study Permit, etc.

STUDENT LEGAL LAST NAME STUDENT LEGAL IRST NAME STUDENT LEGAL SECOND NAME

DATE STUDIES WILL

BE INISHED (MM / DD / YYYY)

if yoU have more children 19 to 24 years of age that are fUll-time stUdents, please checK Box, attach additional sheet and provide all information

HLTH 102 PAG

Personal inormation on this orm is collected under the authority o the Medicare Protection Act. The inormation will be used to determine residency in BC and determine eligibility or provinc

health care benefts. I you have any questions about the collection o this inormation, contact Health Insurance BC at the address or telephone numbers on page 1. Personal inormat

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

CHILD LEGAL LAST NAME CHILD LEGAL IRST NAME CHILD LEGAL SECOND NAME GEND

PERSONAL HEALTH (CARECARD) NUMBER HAS CHILD LIVED IN BC SINCE BIRTH? MM / DD / YYYY ROM (PROVINCE OR COUNTRY) PREVIOUS HEALTH NUMBER

M

f

I NO, MOST RECENT

MOVE TO BCYES

NO






M

f

I NO, MOST RECENT

MOVE TO BCYES

NO






M

f

I NO, MOST RECENT

MOVE TO BCYES

NO




MSP for Dependents - 102fil

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