Fillable SCHEDULE A ASSIGNMENT OF PAYMENT (RBC Insurance)

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SCHEDULE A ASSIGNMENT OF PAYMENT (RBC Insurance)

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Country of origin: CANADA
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(YYYY / MM / DD)
SCHEDULE A
ASSIGNMENT OF PAYMENT
Personal Health Number (PHN) of Patient
BETWEEN
Assignor (Adult Patient, or Parent/Guardian of Patient)
AND
Assignee (Insurance Company) MSP Account Number
900
AND
HER MAJEST
Y THE QUEEN IN THE RIGHT OF THE PROVINCE OF BRITISH COLUMBIA AS REPRESENTED BY
THE MINISTER OF HEALTH SERVICES, hereinafter referred to as the Minister.
WHEREAS the Assignor is a person eligible for insured services and/or benets under the Province of British
Columbia’s Medicare Protection Act and/or Hospital Insurance Act, and as such may receive payment for
certain of those services or benets from the Minister.
And WHEREAS the Assignor is bound by an obligation under a contract or agreement with the Assignee to
remit to the Assignee all payments received for such insured services and/or benets from the Minister.
THEREFORE, in consideration of the obligation to the Assignee, the Assignor hereby assigns to the Assignee
all sums of money that shall be owing to the Assignor by the Minister in relation to the insured services and/
or benets referred to above. The Minister is hereby authorized to pay all such sums directly to the Assignee
at the address noted above, or at any address the Assignee may from time to time designate, with payment
of any such sum to be a complete discharge of the Minister from any indebtedness in the amount to the
Assignor, his heirs, executors, or administrators.
By signing this form, you will be assigning your MSP and hospital insurance benet to the insurance
company (Assignee) named above.
Payment assignment is eective from:
to
(YYYY / MM / DD)
Signature of Assignor (Patient or Parent/Guardian of Patient) Date Signed (YYYY / MM / DD)
HLTH 2806 2018/03/15
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SCHEDULE A ASSIGNMENT OF PAYMENT (RBC Insurance)

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Completed 21 May 2021

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