Fillable OUTOFCOUNTRY MEDICAL CLAIM (RBC Insurance)

Fill Online, Printable, Fillable, Blank OUTOFCOUNTRY MEDICAL CLAIM (RBC Insurance) Form

Use Fill to complete blank online RBC INSURANCE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

OUTOFCOUNTRY MEDICAL CLAIM (RBC Insurance)

On average this form takes 46 minutes to complete

The OUTOFCOUNTRY MEDICAL CLAIM (RBC Insurance) form is 4 pages long and contains:

  • 1 signature
  • 0 check-boxes
  • 180 other fields

Country of origin: CANADA
File type: PDF

Use our library of forms to quickly fill and sign your RBC Insurance forms online.

BROWSE RBC INSURANCE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
FEMALE MALE
HEAD OF FAMILY PATIENT
MOVED
VACATION
OBTAIN MEDICAL CARE
BUSINESS TRIP
STUDENT
NO
OUTOFCOUNTRY MEDICAL CLAIM
IMPORTANT
• This form must be completed and signed by the patient or their legal guardian
• Please read Section B for claim instructions
SECTION A – PATIENT INFORMATION
GENDER
BIRTHDATE (DD / MM / YYYY)
PERSONAL HEALTH NUMBER (PHN) PATIENT FIRST NAME(S) PATIENT LAST NAME
HOME PHONE NUMBER WORK PHONE NUMBER
MAILING ADDRESS CITY / TOWN PROVINCE POSTAL CODE
RESIDENTIAL ADDRESS (IF DIFFERENT FROM ABOVE) CITY / TOWN PROVINCE POSTAL CODE
HAS PATIENT LIVED AT ABOVE ADDRESS FOR THE 6 MONTHS PRECEDING DEPARTURE FROM BC?
YES NO IF NO, PROVIDE BELOW THE RESIDENTIAL ADDRESS(ES) WHERE PATIENT WAS LIVING
PREVIOUS RESIDENTIAL ADDRESS 1 CITY / TOWN PROVINCE POSTAL CODE FROM (MM / YYYY) TO (MM / YYYY)
PREVIOUS RESIDENTIAL ADDRESS 2 CITY / TOWN PROVINCE POSTAL CODE FROM (MM / YYYY) TO (MM / YYYY)
NAME AND ADDRESS OF PRESENT OR LAST EMPLOYER IN BRITISH COLUMBIA
EMPLOYER OF
NAME AND ADDRESS OF A PERSON (NOT A RELATIVE) WHO CAN CONFIRM PATIENT’S RESIDENCE IN BRITISH COLUMBIA (INCLUDE POSTAL CODE)
REASON FOR ABSENCE FROM BRITISH COLUMBIA
DATE OF DEPARTURE FROM BC
MONTH
DAY YEAR
DATE OF RETURN TO BC
OTHER (SPECIFY):
DO YOU HAVE EXTENDED
HEALTH BENEFITS INSURANCE
OR TRAVEL INSURANCE?
YES
IF YES, NAME OF COMPANY POLICY NUMBER
ARE YOU OR ANY DEPENDENTS COVERED BY HEALTH INSURANCE IN ANOTHER COUNTRY?
YES
NO
If yes, attach statement of payment of claims
RELEASE OF INFORMATION
I, the patient named above, hereby authorize Medical Services Plan to obtain information necessary for the processing of my claim from the Hospital
and/or Doctor who provided care or in the event of an appeal on this case to provide the appeal board with the appropriate information in order for an
informed decision to be made.
I also authorize Medical Services Plan to provide/obtain information to/from the above named travel insurance or extended health benets company.
_____________________________
In addition, my signature below is my Application for Benets under the Hospital Insurance Act of British Columbia.
I certify that I am the person entitled to receive benets and that all statements made by me are true and correct.
SIGNATURE OF PATIENT / LEGAL GUARDIAN
DATE SIGNED
If legal guardian, provide name and relationship to patient
NAME OF LEGAL GUARDIAN
RELATIONSHIP TO PATIENT
CONTACT PHONE NUMBER
RESIDENTIAL ADDRESS
Personal information is collected under the authority of the Medicare Protection Act, the Hospital Insurance Act and section 26 (a), (c) and (e) of the Freedom of Information and Protection of Privacy
Act for the purposes of administering provincial health care benets. 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).
HLTH 2814 Rev. 2019/07/03 PAGE 1 OF 4
click to sign
signature
click to edit
SECTION B - GENERAL INFORMATION
CLAIM INSTRUCTIONS
• Attach original receipts and billing invoices to your claim.
• Claims for physician services must be received within 90 days
• Claims for hospital services must be received within 6 months, of the date of discharge
• Receipts and billing invoices not in English or French must include a translation.
• Keep copies of your bills and receipts for your records.
IF YOU HAVE PRIVATE TRAVEL INSURANCE OR AN EXTENDED HEALTH CARE PLAN, CONTACT YOUR TRAVEL PLAN
BEFORE SENDING YOUR CLAIM TO HEALTH INSURANCE BC (HIBC).
FOR MORE INFORMATION:
Ministry of Health and HIBC Website: https://www.health.gov.bc.ca/exforms/msp/occ.html
Please check your claim form is complete and signed.
If the claim indicates the out-of-country physician or hospital has not been paid, payment will be made directly to the out-of-country physician
or hospital.
If the claim is for a small amount or if the out-of-country hospital or physician will not accept payment in Canadian currency, payment will be
sent to the beneciary and the beneciary will be responsible to pay the account.
Please allow 10-12 weeks for processing.
SEND YOUR CLAIM TO: FOR ASSISTANCE, CONTACT:
HEALTH INSURANCE BC HEALTH INSURANCE BC
PO Box 9480 Stn Prov Govt, Victoria BC V8W 9E7 Phone: 604 683-7151 (Lower Mainland), 1 800 663-7100 (Toll-free BC)
PROVINCIAL COVERAGE INFORMATION
EMERGENCY OUT-OF-COUNTRY MEDICAL TREATMENT
When an eligible B.C. resident is temporarily absent from the province and must use emergency medical services in another country, the
provincial coverage is limited.
Provincial coverage for emergency out-of-country:
• physician services is limited to the B.C. physician fee rates
• dental surgery performed in an acute care hospital (patient safety/medical complexity) is limited to the B.C. oral surgery fee rates
• in-patient hospital services is limited to a daily maximum payment of $75.00 CAN
Any dierence in fees will be the beneciary’s responsibility.
For more information, visit the Ministry of Health website: www.gov.bc.ca/MSPCoverage-LeavingBC
ELECTIVE OUT-OF-COUNTRY MEDICAL TREATMENT
If a B.C. resident leaves Canada to obtain medical services in another country, provincial coverage for elective out-of-country medical services
must be requested PRIOR to leaving BC.
Important coverage information and the requirement for medical documentation is available on the Ministry of Health website:
http://www.health.gov.bc.ca/msp/infoben/leavingbc.html#outsidecan
PROVINCIAL COVERAGE IS NOT PROVIDED FOR:
• services that are not deemed to be medically required, such as
cosmetic surgery
• dental oce services
• routine eye examinations for persons 19 to 64 years of age
• eyeglasses, hearing aids, and other equipment or appliances
• annual or routine examinations where there is no medical need
• services of counsellors or psychologists
• certied physician assistant
• registered nurse/nurse practitioner
• prosthesis and appliances
PROVINCIAL COVERAGE IS NOT PROVIDED OUTSIDE B.C. FOR
• ambulance services • podiatry • physical therapy
• massage therapy • optometry • chiropractic
• naturopathy • prescription drugs • acupuncture
• nurse anaesthetist
• health spas and similar facilities
• transportation and accommodation expenses
• supplies and materials
• use of emergency room, private clinic/surgical facility fees
• medical care at the request of a third party
• medical examinations, certicates or tests required for:
°
driving a motor vehicle
°
school or university
°
immigration purposes
°
life insurance
°
employment
°
recreational/sporting activities
• home care services
• midwife services
HLTH 2814 PAGE 2 OF 4
OFFICE
MONTH
HOSPITAL
OFFICE
NO YES
YES
NO
HOME
YES
SECTION C – TO CLAIM FOR DOCTOR’S FEE COMPLETE THIS SECTION
REASON FOR SEEKING MEDICAL ATTENTION (DIAGNOSIS)
TREATMENT / PROCEDURE DURATION OF ANAESTHESIA
HRS MIN
OR
FROM TO
LABORATORY TESTS
AMOUNT PAID
(ENCLOSE PROOF OF PAYMENT)
$
SPECIFY EACH AREA X-RAYED
AMOUNT PAID
(ENCLOSE PROOF OF PAYMENT)
$
PHYSICIAN INFORMATION if more than 7 physicians, attach additional page
**AMOUNT PAID – ENCLOSE PROOF OF PAYMENT
DOCTOR’S NAME AND SPECIALTY COUNTRY AND CURRENCY HAVE YOU PAID THE ACCOUNT?
YES NO
1
WERE YOU REFERRED BY ANOTHER DOCTOR? IF YES, PROVIDE NAME AND ADDRESS
YES NO
DAY YEAR
DAT E
OF VISIT:
TYPE OF VISIT
HOME
TIME OF VISIT
8 AM - 6 PM 6 PM - 11 PM 11 PM - 8 AM
AMOUNT PAID
**
$
DOCTOR’S NAME AND SPECIALTY COUNTRY AND CURRENCY HAVE YOU PAID THE ACCOUNT?
2
WERE YOU REFERRED BY ANOTHER DOCTOR? IF YES, PROVIDE NAME AND ADDRESS
YES NO
MONTH DAY YEAR
DAT E
OF VISIT:
TYPE OF VISIT
HOME HOSPITAL
TIME OF VISIT
8 AM - 6 PM 6 PM - 11 PM 11 PM - 8 AM
AMOUNT PAID
**
$
DOCTOR’S NAME AND SPECIALTY COUNTRY AND CURRENCY HAVE YOU PAID THE ACCOUNT?
YES NO
3
WERE YOU REFERRED BY ANOTHER DOCTOR? IF YES, PROVIDE NAME AND ADDRESS
MONTH DAY YEAR
DAT E
OF VISIT:
TYPE OF VISIT
OFFICE HOME HOSPITAL
TIME OF VISIT
8 AM - 6 PM 6 PM - 11 PM 11 PM - 8 AM
AMOUNT PAID
**
$
DOCTOR’S NAME AND SPECIALTY COUNTRY AND CURRENCY HAVE YOU PAID THE ACCOUNT?
YES NO
4
WERE YOU REFERRED BY ANOTHER DOCTOR? IF YES, PROVIDE NAME AND ADDRESS
YES NO
MONTH DAY YEAR
DAT E
OF VISIT:
TYPE OF VISIT
OFFICE HOSPITAL
TIME OF VISIT
8 AM - 6 PM 6 PM - 11 PM 11 PM - 8 AM
AMOUNT PAID
**
$
DOCTOR’S NAME AND SPECIALTY COUNTRY AND CURRENCY HAVE YOU PAID THE ACCOUNT?
YES NO
5
WERE YOU REFERRED BY ANOTHER DOCTOR? IF YES, PROVIDE NAME AND ADDRESS
YES NO
MONTH DAY YEAR
DAT E
OF VISIT:
TYPE OF VISIT
OFFICE HOME HOSPITAL
TIME OF VISIT
8 AM - 6 PM 6 PM - 11 PM 11 PM - 8 AM
AMOUNT PAID
**
$
DOCTOR’S NAME AND SPECIALTY COUNTRY AND CURRENCY HAVE YOU PAID THE ACCOUNT?
YES NO
6
WERE YOU REFERRED BY ANOTHER DOCTOR? IF YES, PROVIDE NAME AND ADDRESS
YES NO
MONTH DAY YEAR
DAT E
OF VISIT:
TYPE OF VISIT
OFFICE HOME HOSPITAL
TIME OF VISIT
8 AM - 6 PM 6 PM - 11 PM 11 PM - 8 AM
AMOUNT PAID
**
$
DOCTOR’S NAME AND SPECIALTY COUNTRY AND CURRENCY HAVE YOU PAID THE ACCOUNT?
NO
7
WERE YOU REFERRED BY ANOTHER DOCTOR? IF YES, PROVIDE NAME AND ADDRESS
YES NO
MONTH DAY YEAR
DAT E
OF VISIT:
TYPE OF VISIT
OFFICE HOME HOSPITAL
TIME OF VISIT
8 AM - 6 PM 6 PM - 11 PM 11 PM - 8 AM
AMOUNT PAID
**
$
HLTH 2814 PAGE 3 OF 4
SECTION D – TO CLAIM FOR IN-PATIENT HOSPITAL CHARGES COMPLETE THIS SECTION
• In-patient hospital charges include registered bed patient, dialysis, and surgical day care.
• Sections A and C must be completed in the fullest possible detail to conrm residency and entitlement for hospital benets. See Section D for
residency requirements.
• A separate application is required for each admission to hospital.
• If the condition of the person requiring admission to hospital does not permit him/her to apply on his/her own behalf, or if he/she is an underage dependent,
this form should be completed by a member of the family or some other person having knowledge of the facts.
NAME OF HOSPITAL
MAILING ADDRESS OF HOSPITAL, INCLUDING POSTAL CODE
ADMITTING DIAGNOSIS (NATURE OF ILLNESS) AND TREATMENT PROVIDED DURING HOSPITALIZATION
DATE OF
ADMISSION:
MONTH DAY YEAR
DAT E
OF DISCHARGE:
MONTH DAY YEAR
HAVE YOU PAID THE
HOSPITAL ACCOUNT?
YES
NO
AMOUNT PAID (ENCLOSE PROOF OF PAYMENT)
$
RESIDENCY INFORMATION
A person must be a B.C. resident to qualify for medical coverage under MSP. A resident is a person who meets all of the following conditions:
• must be a citizen of Canada or be lawfully admitted to Canada for permanent residence;
• must make his or her home in B.C.; and
• must be physically present in B.C. at least six months in a calendar year, or a shorter prescribed period.*
* Eligible B.C. residents (citizens of Canada or persons who are lawfully admitted to Canada for permanent residence) who are
outside B.C. for vacation purposes only, are allowed a total absence of up to seven months in a calendar year.
For more information:
https://www2.gov.bc.ca/gov/content/health/health-drug-coverage/msp/bc-residents/eligibility-and-enrolment/are-you-eligible
HLTH 2814 PAGE 4 OF 4
RESET
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

OUTOFCOUNTRY MEDICAL CLAIM (RBC Insurance)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 21 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document