Fillable BC heath insurance MSP GROUP CHANGE REQUEST

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BC heath insurance MSP GROUP CHANGE REQUEST

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Country of origin: CANADA
File type: PDF

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CHANGE/CORRECT ACCOUNT HOLDER’S INFORMATION – Complete sections 2 (with new/correct information) and 4, and take this form to
your Group Administrator to authorize (section 5). Legal documents are required for MSP to conrm a change or correction.
CHANGE ADDRESS INFORMATION – Complete sections 2, 3, 4 and take this form to your Group Administrator to authorize.
ADD, REMOVE OR CHANGE/CORRECT INFORMATION FOR A SPOUSE – Complete sections 2 and 7. If you are adding a spouse, complete section 9.
Take this form to your Group Administrator to authorize.
ADD, REMOVE OR CHANGE/CORRECT INFORMATION FOR A CHILD – Complete sections 2 and 8. If you are adding a spouse, complete section 9.
Take this form to your Group Administrator to authorize.
CHANGE GROUP PLAN INFORMATION (GROUP ADMINISTRATOR USE ONLY) – Complete sections 2, 5 and 6.
HLTH 170 V8 Rev. 2019/07/08
BIRTHDATE (MM / DD / YYYY)
RESIDENTIAL ADDRESS CITY PROV POSTAL CODE
MAILING ADDRESS (IF DIFFERENT FROM RESIDENTIAL ADDRESS) CITY PROV POSTAL CODE
I understand the information I have given is collected under the authority of the Medicare Protection Act and may be used to assess eligibility for other
Ministry of Health programs, and that practitioners who provide service(s) under MSP are required under the Medicare Protection Act to release information
relative to those services to MSP to support claims for benets.
I declare that all information provided is true and I understand that the Ministry 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.
Residents of BC are required, by law, to enrol themselves and to enrol their spouse and children who are residents of BC.
The BC Services Card provides access to insured provincial health care benets for eligible BC residents. If adding a spouse who is a new or returning adult resident, the spouse
should rst visit an Insurance Corporation of BC (ICBC) driver licensing oce to begin a BC Services Card request. To nd an ICBC driver licensing oce near you, and information
about required ID, please visit icbc.com. After the spouse has visited an ICBC driver licensing oce, submit this Group Change Request form.
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.
2 ACCOUNT HOLDER INFORMATION  THIS SECTION MUST BE COMPLETED
4 AUTHORIZATION MUST BE SIGNED (DO NOT CHANGE TEXT OF AUTHORIZATION BELOW)
ACCOUNT HOLDER LEGAL LAST NAME ACCOUNT HOLDER LEGAL FIRST NAME ACCOUNT HOLDER LEGAL SECOND NAME
Mailing Address: Health Insurance BC, Medical Services Plan, PO Box 9691 Stn Prov Govt, Victoria BC V8W 9P8
Tel: (Lower Mainland) 604 683-7520, (Rest of BC) 1 877 955-5656 Web: www.hibc.gov.bc.ca
AUTHORIZATION NAME OR STAMP
GROUP NUMBER
SIGNATURE OF ACCOUNT HOLDER DATE SIGNED MM / DD / YYYYSIGNATURE OF ACCOUNT HOLDER’S SPOUSE
PERSONAL HEALTH NUMBER (PHN)
DAYTIME TELEPHONE NUMBER
1 CHANGE REQUESTMARK ALL THAT APPLY
3 ADDRESS CHANGEPLEASE PROVIDE NEW ADDRESS INFORMATION
5 GROUP ADMINISTRATOR  AUTHORIZATION REQUIRED 6 CHANGE GROUP PLAN INFORMATION
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 Oce at Health Insurance BC, Chief
Privacy Oce, PO Box 9035 STN PROV GOVT, Victoria, BC V8W 9E3 or call 604 683-7151 (Vancouver) or 1 800 663-7100 (toll-free).
OLD DEPT / PAYLIST NUMBER
MEDICAL SERVICES PLAN MSP
GROUP CHANGE REQUEST
GC
PLEASE USE
CAPITAL LETTERS ONLY
ABCD
GENDER
OLD EMPLOYEE / PENSION NUMBER
M
F
NEW DEPT / PAYLIST NUMBER
NEW EMPLOYEE / PENSION NUMBER
7 SPOUSE
SPOUSE LEGAL LAST NAME SPOUSE LEGAL FIRST NAME SPOUSE LEGAL SECOND NAME
BIRTHDATE (MM / DD/ YYYY)
PERSONAL HEALTH NUMBER (PHN)
GENDER
M
F
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.
➤
Continued on p. 2
SPOUSE EFFECTIVE DATE, IF APPLICABLE (MM / DD / YYYY)
HAS CHILD LIVED IN BC SINCE BIRTH? MM / DD / YYYY FROM (PROVINCE OR COUNTRY) IS THIS A PERMANENT MOVE?
→
ADD CHILD TO PLAN
REQUESTED EFFECTIVE
DATE (MM / DD / YYYY) (MM / DD / YYYY)
PROVIDE PHOTOCOPIES OF ALL APPLICABLE DOCUMENTS (DO NOT SEND ORIGINALS). IF LEGAL NAME DOES NOT MATCH,
INCLUDE COPY OF CHANGE OF NAME CERTIFICATE, ETC.
→
IF CHILD IS NEWLY ADOPTED,
INDICATE DATE OF ADOPTION
→
ENCLOSE PROOF OF ADOPTION
➤
YES
NO
YES
NO
CANADIAN CITIZENCanadian Birth
Certicate, Canadian Citizenship Card
or Passport
HOLDER OF PERMANENT RESIDENT
STATUS  Record of Landing, Permanent
Resident Card (front & back) or
Conrmation of Permanent Residence
OTHER  Work or Study Permit, etc.
STATUS IN CANADA (MARK ONE –
X
)
IF NO, MOST RECENT
MOVE TO BC
9 ADDITIONAL REQUIRED INFORMATION  FAILURE TO PROVIDE THIS INFORMATION MAY AFFECT ELIGIBILITY FOR BENEFITS
IF YOU ARE ADDING, REMOVING OR CHANGING INFORMATION FOR MORE THAN
ONE CHILD, MARK THE BOX, ATTACH ADDITIONAL SHEET AND PROVIDE
ALL INFORMATION.
HLTH 170 PAGE 2
HAS SPOUSE LIVED IN BC SINCE BIRTH? MM / DD / YYYY FROM (PROVINCE OR COUNTRY)
→
REMOVE SPOUSE FROM PLAN: COMPLETE STEPS 1 AND 2, SUBMIT COPIES OF DOCUMENTS AS REQUIRED.
CANCELLATION DATE (MM / DD / YYYY)
REASON FOR CANCELLATION
CITY PROV POSTAL CODE
ADD SPOUSE TO PLAN: COMPLETE STEPS 1 AND 2, SUBMIT COPIES OF DOCUMENTS AS REQUIRED. If legal name does not match, include copy of marriage/change of name certicate, etc.
MARRIAGE DATE (MM / DD / YYYY) SPOUSE’S PREVIOUS LAST NAME (IF APPLICABLE)
YES
NO
CHANGE/CORRECT SPOUSE’S INFORMATION
8 CHILD
REMOVE CHILD FROM PLAN
CANCELLATION DATE (MM / DD / YYYY)
REASON FOR CANCELLATION
CHILD’S CURRENT MAILING ADDRESS CITY PROV POSTAL CODE
CHANGE/CORRECT CHILD’S INFORMATION
IF ANYONE LISTED IS AN ACTIVE MEMBER OF, OR HAS BEEN RELEASED FROM, THE CANADIAN ARMED FORCES, RCMP OR AN INSTITUTION, PROVIDE NAME AND, IF APPLICABLE, DISCHARGE DATE:
(MM / DD / YYYY)
HAVE YOU OR ANY FAMILY MEMBER BEEN OUTSIDE BC FOR MORE THAN 30 DAYS IN TOTAL IN THE PAST 12 MONTHS?
YES NO
IF YES, PROVIDE DETAILS BELOW.
WILL YOU OR ANY FAMILY MEMBER BE OUTSIDE BC FOR MORE THAN 30 DAYS IN TOTAL IN THE NEXT 6 MONTHS?
YES NO IF YES, PROVIDE DETAILS BELOW.
RETURN DATE (MM / DD / YYYY)DEPARTURE DATE (MM / DD / YYYY)
FAMILY MEMBER NAME, REASON FOR DEPARTURE AND LOCATION
LEGAL DOCUMENTS ARE REQUIRED FOR MSP TO CONFIRM A CHANGE OR CORRECTION. PROVIDE PHOTOCOPY OF
APPLICABLE DOCUMENT; e.g., PROOF OF STATUS IN CANADA SEE BELOW OR CHANGE OF NAME CERTIFICATE.
LEGAL DOCUMENTS ARE REQUIRED FOR MSP TO CONFIRM A CHANGE OR CORRECTION. PROVIDE PHOTOCOPY OF
APPLICABLE DOCUMENT; E.G. PROOF OF STATUS IN CANADA SEE BELOW OR MARRIAGE/CHANGE OF NAME CERTIFICATE.
➤
➤
➤
➤
➤
CHILD LEGAL LAST NAME CHILD LEGAL FIRST NAME CHILD LEGAL SECOND NAME
NAME
BIRTHDATE (MM / DD/ YYYY)
PERSONAL HEALTH NUMBER (PHN)
GENDER
M
F
IF NO, MOST RECENT
MOVE TO BC
UNKNOWN
UNKNOWN
7 SPOUSE CONTINUED
IS THIS A PERMANENT MOVE? REG. # OF MEDICAL PLAN IN PREVIOUS PLACE OF RESIDENCE
YES
NO
2. ADDITIONAL DETAILS:1. SPOUSE ENROLMENT IN MSP:
A. My spouse is currently enrolled in MSP (go to Step 2); OR
B. My spouse is not currently enrolled in MSP (indicate their status in Canada
below and submit copies of the required documents to verify identity and
citizenship status, then go to Step 2):
CANADIAN CITIZENCanadian Birth Certicate, Canadian Citizenship
Card or Passport
HOLDER OF PERMANENT RESIDENT STATUS  Record of Landing,
Permanent Resident Card (front & back) or Conrmation of Permanent
Residence
OTHER  Work or Study Permit, etc.
2. CANCELLATION DETAILS:1. INDICATE ONE OF THE FOLLOWING
A. I am removing a spouse but we are still married or living in a marriage-like relationship (go to Step 2); OR
B. I am removing a spouse who has died (go to Step 2); OR
C. I am removing a spouse following a divorce or separation (indicate below):
My former spouse has moved permanently from British Columbia (go to Step 2); OR
My former spouse is still a resident of British Columbia or I do not know my former spouse’s current address
(submit a photocopy of one of the supporting documents indicated below, then go to Step 2):
Divorce decree (if formerly married)
Separation agreement (formerly married or common-law)
Notarized statement or adavit (signed by at least one spouse) (formerly married or common-law)
Statement dated and signed by you and/or your spouse including:
• the date of your divorce or separation • full names of you and your former spouse
• your former spouse’s current address, or an indication that the address is unknown
• Account Numbers or PHNs for you and your spouse.
SPOUSE’S MAILING ADDRESS
CHILD means a BC resident who is a child of a beneciary or a person in respect of whom a beneciary stands in the place of a parent, and who is a minor, does not have a spouse, and is supported by the beneciary.
SCHOOL NAME AND FULL ADDRESS
ORIGINAL DEPARTURE DATE MM / DD / YYYY*
IF THE ABOVE CHILD IS A DEPENDENT POST-SECONDARY STUDENT, PLEASE ALSO COMPLETE THE SECTION BELOW.
DATE STUDIES END MM / DD / YYYY
*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.
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.
DATE STUDIES BEGIN MM / DD / YYYY
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BC heath insurance MSP GROUP CHANGE REQUEST

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Completed 12 January 2020

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