To be completed by new applicants who do not have a valid MSP
billing number; are registered with the College of Dental Surgeons of
British Columbia and wish to obtain a Medical Services Plan billing number.
LEGAL
NAME
DATE
OF
BIRTH
DATE OF ENTRY (MM / DD / YYYY)
GRADUATED FROM:
DATE OF REGISTRATION (MM / DD / YYYY) COLLEGE REGISTRATION #
OPT IN (BILL THE MEDICAL SERVICES PLAN)
OPT OUT (BILL THE PATIENT)
temporary license
full license
EFFECTIVE DATE (MM / DD / YYYY)
SURNAME
MM DD YYYY
2. EDUCATION AND CERTIFICATION
To apply for Direct Bank Payment from MSP BC, please complete the Application for Direct Bank Payment (HLTH 2832), https://www2.gov.bc.ca/assets/gov/health/forms/2832l.pdf
GIVEN NAME (FIRST) GIVEN NAME (SECOND)
BUSINESS MAILING ADDRESS CITY POSTAL CODE
PHONE NUMBER
HOME ADDRESS (NUMBER AND STREET) CITY POSTAL CODE
PHONE NUMBER
DATE OF GRADUATION (MM / DD / YYYY)
EFFECTIVE DATE (MM / DD / YYYY)
EFFECTIVE DATE (MM / DD / YYYY)
EFFECTIVE DATE (MM / DD / YYYY) CANCELLATION DATE (MM / DD / YYYY)
IMPORTANT: DO YOU WISH TO BE OPTED IN OR OPTED OUT OF THE MEDICAL SERVICES PLAN?
HLTH 2994 2020/04/01
FAX NUMBER
FAX NUMBER
EMAIL ADDRESS
EMAIL ADDRESS
EFFECTIVE DATE (MM / DD / YYYY)
EFFECTIVE DATE (MM / DD / YYYY)
EFFECTIVE DATE (MM / DD / YYYY)
EFFECTIVE DATE (MM / DD / YYYY)
EFFECTIVE DATE (MM / DD / YYYY)
EFFECTIVE DATE (MM / DD / YYYY)
CHECK APPLICABLE SPECIALTYS:
ENDODONTIST
GENERAL PRACTITIONER DENTIST
ORAL & MAXILLOFACIAL SURGEON
ORAL MEDICINE
ORTHODONTIST
PEDIATRIC DENTIST
PERIODONTIST
PROSTHODONTIST
or
APPLICATION FOR MSP BILLING NUMBER DENTAL
If non-Canadian, indicate your status in Canada and
enclose a copy of your Work Permit and/or Landed
Immigrant status papers.
1. PERSONAL INFORMATION
2. EDUCATION AND CERTIFICATION
3. REGISTRATION: COLLEGE OF DENTAL SURGEONS OF BRITISH COLUMBIA
4. PAYMENT
Mailing Address: Provider Programs, PO Box 9480 Stn Prov Govt, Victoria BC V8W 9E7
Tel: (Lower Mainland) 604 456-6950, (Rest of BC) 1 866 456-6950 FAX: 250 405-3592 Web: www.hibc.gov.bc.ca
Personal information is collected under the authority of the Medicare Protection Act and section 26 (a), (c) and (e) of the Freedom of Information and Protection of Privacy Act for the purposes of administration
of the Medical Services Plan. If you have any questions about the collection and use of your personal information, please contact the Health Insurance BC Chief Privacy Oce at Health Insurance BC,
Chief Privacy Oce, PO Box 9035 STN Prov Govt, Victoria BC V8W 9E3 or call 604-683-7151 (Vancouver) or 1-800-663-7100 (toll free).
5. DECLARATION AND SIGNATURE
I understand that MSP is a public system based on trust, but also that my claims are subject to audit
and nancial recovery for claims contrary to the Medicare Protection Act (the “Act”). I undertake to not
submit false or misleading claims information, and acknowledge that doing so is an oence under
the Act and may be an oence under the Criminal Code of Canada. Further, I agree that I will meet
the requirements of the Act and related Payment Schedule regarding claims for payment, including
that prior to submitting a claim I must create: (a) an adequate medical record, if I am a medical
practitioner; or (b) an adequate clinical record, if I am a health care practitioner.
SIGNATURE
DATE SIGNED
CITIZENSHIP
M
F
OTHER
