Fillable SB ABCD APPLICATION FOR SUPPLEMENTARY BENEFITS (Camosun College)

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SB ABCD APPLICATION FOR SUPPLEMENTARY BENEFITS (Camosun College)

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MEDICAL SERVICES PLAN MSP
APPLICATION FOR
SUPPLEMENTARY BENEFITS
HLTH 103 V 4 Rev. 2021/05/11
APPLICANT INFORMATION
Mailing Address: Health Insurance BC, Medical Services Plan, PO Box 9677 Stn Prov Govt, Victoria BC V8W 9P7
Tel: (Lower Mainland) 604 683-7151, (Rest of BC) 1 800 663-7100 Web: www.hibc.gov.bc.ca
ABCD
APPLICANT LEGAL LAST NAME APPLICANT LEGAL FIRST NAME APPLICANT LEGAL SECOND NAME
This form must be signed. We cannot accept unsigned forms. See page 2 for the Adjusted Net Income calculation worksheet.
APT / UNIT STREET NUMBER STREET NAME
CITY PROVINCE POSTAL CODE
PERSONAL HEALTH NUMBER (PHN) BIRTHDATE (MM / DD / YYYY) DAYTIME TELEPHONE NUMBER
USE CAPITAL LETTERS ONLY
MAILING ADDRESS:
MSP supplementary benets provide partial payment for certain medical services obtained in British Columbia and may provide access to other
income-based programs. For more information and to apply online, see www.gov.bc.ca/MSP/supplementarybenets. To be assessed for supplementary benets,
you must submit this form to Health Insurance BC (HIBC) with a copy of your most recent Notice of Assessment (NOA) or Notice of Reassessment (NORA) from
Canada Revenue Agency (CRA). Ensure the applicable name, tax year and tax return line 23600 (net income) are included.
SB
MSP enrolment must be complete for you (and your spouse, if applicable) to qualify for MSP supplementary benets. To complete MSP enrolment, submit the MSP Application for
Enrolment form and obtain a Photo BC Services Card by visiting an Insurance Corporation of BC (ICBC) driver licensing oce. To nd an ICBC driver licensing oce near you, please visit
www.icbc.com.
Eligibility for supplementary benets may be impacted if you do not le your income tax return with CRA each year; or if you do not update your MSP account if you marry or begin
living in a marriage-like relationship.
Income Verication - The signed declaration above allows the Ministry of Health and/or Health Insurance BC to verify your income information with CRA on an ongoing basis. In most
cases, you do not need to reapply for supplementary benets as Health Insurance BC will continue to verify your income with CRA each year and will adjust your eligibility based on the
information received from CRA. In order to verify your income, the name and date of birth on your MSP account must match the information on le at CRA.
Fair PharmaCare - If you are already registered in Fair PharmaCare and have experienced a decrease in income, you might qualify for
increased Fair PharmaCare coverage. For more information or to register, visit www.gov.bc.ca/pharmacare or contact HIBC.
APPLICANT SIGNATURE SPOUSE SIGNATURE DATE SIGNED MM / DD / YYYY
DECLARATION AND CONSENT  MUST BE SIGNED
Mark (
X
) if you are married or living and cohabiting in a marriage-like relationship (even if your spouse is not covered under your MSP account) and include his/her
information (below) with your application.
Mark (
X
) if someone has Power of Attorney or another legal representation agreement and is signing on your behalf, and include a copy of the agreement with
your application.
I (applicant) am a resident of British Columbia as dened by the Medicare Protection Act.
I (applicant) have resided in Canada as a Canadian citizen or holder of permanent resident status (landed immigrant) for at least the last 12 months immediately preceding this application.
I am not exempt from liability to pay income tax by reason of any other Act.
I (applicant and, if applicable, spouse) hereby consent to the release of information from my income tax returns, and other taxpayer information, by the Canada Revenue Agency to the
Ministry of Health and/or Health Insurance BC. The information obtained will be relevant to and used for the purpose of determining and verifying my initial and ongoing entitlement to
the Supplementary Benets Program under the Medicare Protection Act, and will not be disclosed to any other party. This authorization is valid for the taxation year prior to the signature of
this application, the year of the signature and for each subsequent consecutive taxation year for which supplementary benets is requested. It may be revoked by sending a written notice
to Health Insurance BC.
MEDICAL SERVICES PLAN SUPPLEMENTARY BENEFITS INFORMATION
APPLICANT FIRST INITIAL AND LAST NAME SPOUSE FIRST INITIAL AND LAST NAME
APPLICANT SOCIAL INSURANCE NUMBER SPOUSE SOCIAL INSURANCE NUMBER SPOUSE PERSONAL HEALTH NUMBER (PHN)
Please read and sign. If you are married or living in a marriage-like relationship, your spouse must also sign.
If someone has Power of Attorney or another legal representation agreement and is signing on your behalf, include a copy of the agreement.
HLTH 103 PAGE 2
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).
FINANCIAL INFORMATION
NET INCOME
1 Enter your net income (from your Notice of Assessment or Notice of Reassessment)
$
,
1
Note: If net income is a negative number (e.g. – $2,300.00), enter 0
2 Enter the net income of your spouse $
,
2
Note: If net income is a negative number (e.g. – $2,300.00), enter 0
3 TOTAL NET INCOME (add lines 1 and 2) $
,
3
DEDUCTIONS ALLOWED BY THE MEDICAL SERVICES PLAN (MSP)
4 SPOUSE -
if you are married or living in a marriage-like relationship, claim $3,000
$
,
4
5 If you are 65 or older, claim $3,000 $
,
5
6 If your spouse is 65 or older, claim $3,000 $
,
6
CHILDREN x $3,000 = $
,
number of minors/dependent post-secondary students
minus one half of the child care expenses
claimed on your (or your spouse’s)
income tax return (1/2 of line 21400) – $
,
7 Dierence (if a negative number, enter 0) = $
,
➮ $
,
7
8 DISABILITY x $3,000 = $
,
8
number of disabled individuals on account
Note: Provide a letter from CRA showing eligibility for the applicable tax year.
9 Registered Disability Savings Plan income reported on your
(and/or your spouse’s) income tax return (line 12500)
$
,
9
10 TOTAL DEDUCTIONS (add lines 4 to 9) $
,
10
ADJUSTED NET INCOME
11 ADJUSTED NET INCOME (subtract line 10 from line 3) $
,
11
Note: If this amount is $42,000 or less, you may be eligible for supplementary benets.
UNIVERSAL CHILD CARE BENEFIT
If your NOA or NORA indicates a
retroactive Universal Child Care
Benet (UCCB) payment (line
11700), HIBC will assess a deduction
to your Adjusted Net Income.
CHILDREN
Claim $3,000 for each minor (under
19 years of age) or dependent post-
secondary student (19-24 years of
age; may include a student enrolled
in full-time studies at a trade school,
technical school or high school)
included under your MSP coverage.
DISABILITY
If you claimed a disability on your
income tax return for yourself, or
your spouse, minor or dependent
post-secondary student included
under your MSP coverage, claim
$3,000 for each disabled person.
If you claimed attendant or nursing
home expenses in place of disability,
enclose photocopies of receipts.
ADJUSTED NET INCOME
is net income from your
Notice of Assessment or Notice
of Reassessment minus above
deductions allowed by MSP.
Net income is found on line 23600
of the CRA Notice of Assessment or
Notice of Reassessment.
2 0
TAX YEAR
Include a photocopy of your Notice of Assessment (NOA) or Notice of Reassessment (NORA) (and your
spouse’s, if applicable) for the tax year indicated. This information is from my NOA/NORA for the tax year:
Use the latest NOA/NORA available
from CRA.
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SB ABCD APPLICATION FOR SUPPLEMENTARY BENEFITS (Camosun College)

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Completed 19 January 2022

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