"Medical Services Plan (Msp) Application for Enrolment" - British Columbia, Canada

What Is Form HLTH 102?

Form HLTH 102, MEDICAL SERVICES PLAN (MSP) APPLICATION FOR ENROLMENT, is a document that can be used by individuals who want to enter the Medical Service Plan (MSP). The MSP is a health insurance program that provides its members with health care benefits, that can cover the services of physicians and other health care practitioners.

Alternate Name:

  • MSP Application Form.

The application was issued by the British Columbia (BC) Ministry of Health and was last revised on January 1, 2020. A fillable MSP Application is available for download below.

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MSP Application Form Instructions

An MSP Application Form can only be used by BC residents. Completing the document is a straightforward process, however, if the individual is completing it for the first time it might cause difficulties. Form HLTH 102 is presented on four pages, which consist of two pages of guidelines and the form itself. The document contains several parts, which include the following:

  1. Information About the Applicant. In the first part of the document, the individual can state their full name, date of birth, telephone number, residential address, and mailing address (if it is different from their residential address).
  2. Residence and Citizenship. Here, the individual is supposed to designate their status in Canada, whether they had the MSP coverage before, if they have lived in BC since they were born, and answer other questions connected with their occupation and trips.
  3. Spouse and Child Information. Individuals can use this part to provide information about their spouse and children (if applicable). It should include their spouse's and child's full name, date of birth, status in Canada, where they are from, etc.
  4. Supplementary Benefits. This section of the application provides the individual with information about how benefits work. It also states that the requirements and information about eligibility can be found on the official website of the government of BC.
  5. Authorization. By signing this part of the document, the individual agrees to comply with the terms and rules of the MSP, authorizes the BC Ministry of Health to collect their information, and declares that everything stated in the form is true and correct. If the document contains information about the individual's spouse, they are supposed to sign this part of the form as well.
  6. Important Information. In the last section of the document, the individual can find important statements related to the address change, name change, additional documents that must be attached to the form, and other important statements.
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Applying for the
Medical Services Plan (MSP)
This is a reference document to help you apply for enrolment in the Medical Services Plan (MSP). MSP covers provincially insured
health care benefits for British Columbia (BC) residents. If you are a BC resident, by law, you must enrol. You also must enrol your
spouse and any children who are BC residents.
Status First Nations individuals in BC should apply through the First Nations Health Authority at www.fnha.ca/benefits/eligibility-and-msp.
Apply Online
Did you know you can apply online at www.gov.bc.ca/msp/applyforhealthcare? The application process takes about 15 minutes
and provides step by step instructions.
Already have an MSP account and want to make changes?
If you already have an MSP account, do not fill out this application to make changes. You can update your address, change your
coverage or add a family member online at www.gov.bc.ca/managingyourmspaccount.
Who Qualifies for MSP
To qualify for MSP health care benefits, you must meet BC residency requirements. If you are applying for MSP for your spouse
or children who reside in BC, they also must meet these requirements. Please see the Application for Enrolment for the definition
of resident.
Absences from BC:
You must indicate if you have been absent from BC for more than 30 days in total during the past 12 months. (See Section 2D on
the Application for Enrolment).
If you plan to leave the province for more than 30 days in total during the next 6 months, include a letter with your planned dates
of departure and return, your destination, and reason for your absence: this must be approved before health care benefits will be
provided. (See Section 2E on the Application for Enrolment).
A few things to keep in mind:
• use full legal names for everyone on the application
• do not include anyone who is not a BC resident
• do not include anyone other than you, and your spouse and children if they reside in BC
• applicants must be physically in BC when applying for MSP
Accepted Identification
Provide a photocopy of one of the following identification documents for everyone on the application. Your documents must show
both legal name and legal status in Canada. (See Section 2A and 3 on the Application for Enrolment). If you do not have one of the
following documents but believe you may be eligible for MSP enrolment, contact HIBC.
For Canadian Citizens
For Permanent Residents
For Temporary Document Holders
• Canadian Birth Certificate
• Permanent Resident Card
• Study Permit
(front and back)
• Canadian Citizenship Card
• Work Permit (Note: Applicant on
(front and back)
• Record of Landing
working holiday must include a letter
of employment)
• Certificate of Canadian Citizenship
• Confirmation of Permanent
(front and back)
Residence Letter
• Canadian Passport
If you or any person on your application is enrolling under a name that is different from the name shown on their identification
document, you must also submit a photocopy of one of the following, that indicates the name shown on the application:
• marriage certificate
• name change certificate, or
• divorce decree
Page 1 of 2
Applying for the
Medical Services Plan (MSP)
This is a reference document to help you apply for enrolment in the Medical Services Plan (MSP). MSP covers provincially insured
health care benefits for British Columbia (BC) residents. If you are a BC resident, by law, you must enrol. You also must enrol your
spouse and any children who are BC residents.
Status First Nations individuals in BC should apply through the First Nations Health Authority at www.fnha.ca/benefits/eligibility-and-msp.
Apply Online
Did you know you can apply online at www.gov.bc.ca/msp/applyforhealthcare? The application process takes about 15 minutes
and provides step by step instructions.
Already have an MSP account and want to make changes?
If you already have an MSP account, do not fill out this application to make changes. You can update your address, change your
coverage or add a family member online at www.gov.bc.ca/managingyourmspaccount.
Who Qualifies for MSP
To qualify for MSP health care benefits, you must meet BC residency requirements. If you are applying for MSP for your spouse
or children who reside in BC, they also must meet these requirements. Please see the Application for Enrolment for the definition
of resident.
Absences from BC:
You must indicate if you have been absent from BC for more than 30 days in total during the past 12 months. (See Section 2D on
the Application for Enrolment).
If you plan to leave the province for more than 30 days in total during the next 6 months, include a letter with your planned dates
of departure and return, your destination, and reason for your absence: this must be approved before health care benefits will be
provided. (See Section 2E on the Application for Enrolment).
A few things to keep in mind:
• use full legal names for everyone on the application
• do not include anyone who is not a BC resident
• do not include anyone other than you, and your spouse and children if they reside in BC
• applicants must be physically in BC when applying for MSP
Accepted Identification
Provide a photocopy of one of the following identification documents for everyone on the application. Your documents must show
both legal name and legal status in Canada. (See Section 2A and 3 on the Application for Enrolment). If you do not have one of the
following documents but believe you may be eligible for MSP enrolment, contact HIBC.
For Canadian Citizens
For Permanent Residents
For Temporary Document Holders
• Canadian Birth Certificate
• Permanent Resident Card
• Study Permit
(front and back)
• Canadian Citizenship Card
• Work Permit (Note: Applicant on
(front and back)
• Record of Landing
working holiday must include a letter
of employment)
• Certificate of Canadian Citizenship
• Confirmation of Permanent
(front and back)
Residence Letter
• Canadian Passport
If you or any person on your application is enrolling under a name that is different from the name shown on their identification
document, you must also submit a photocopy of one of the following, that indicates the name shown on the application:
• marriage certificate
• name change certificate, or
• divorce decree
Page 1 of 2
Applying for the
Medical Services Plan (MSP)
Effective Date of Benefits
New and returning residents must complete a wait period before health care benefits begin. This period is generally the balance
of the month of arrival in BC, plus two months. Submit your application immediately when you arrive in BC. If you apply late, a
different MSP effective date may be assigned.
Mailing Your Application Form
Make sure you have included all required information and supporting documents. If not, the process might be delayed. Make sure
you, and your spouse if applicable, have signed and dated the second page.
To complete MSP enrolment, most adults must get a photo BC Services Card. You can get one at an Insurance Corporation of BC
(ICBC) driver licensing office. Health Insurance BC (HIBC) and ICBC accept different primary and secondary identification. Before
attending ICBC please confirm you have the appropriate identification at www.icbc.com/acceptedID. Children and Temporary
Document Holders are not required to attend an ICBC office and will be issued a non-photo BC Services Card.
Page 2 of 2
MEDICAL SERVICES PLAN (MSP)
APPLICATION FOR ENROLMENT
PLEASE PRINT IN CAPITAL LETTERS ONLY
1 2 3 4 A B C D
This form may also be completed and submitted online at
www.gov.bc.ca/MSP/applyforhealthcare
To complete MSP enrolment, adult Canadian Citizens and Permanent Residents must obtain a Photo BC Services Card by visiting an Insurance Corporation of BC
(ICBC) driver licensing office. To find an ICBC driver licensing office near you, please visit www.icbc.com.
Residents of BC are required, by law, to enrol themselves and to enrol their spouse and children who are residents of BC.
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.
1 APPLICANT INFORMATION
APPLICANT LEGAL LAST NAME
APPLICANT LEGAL FIRST NAME
APPLICANT LEGAL SECOND NAME
BIRTHDATE (MM / DD/ YYYY)
GENDER
DAYTIME TELEPHONE NUMBER
As a person must be a resident of BC to qualify for provincial health care benefits,
M
your current residential address is required.
F
RESIDENTIAL ADDRESS
CITY
PROV
POSTAL CODE
MAILING ADDRESS (IF DIFFERENT FROM RESIDENTIAL ADDRESS)
CITY
PROV
POSTAL CODE
2 RESIDENCE AND CITIZENSHIP / IMMIGRATION INFORMATION
STATUS IN CANADA - PROVIDE PHOTOCOPIES OF ALL APPLICABLE DOCUMENTS (DO NOT SEND ORIGINALS)
A
CANADIAN CITIZEN – Canadian Birth Certificate,
HOLDER OF PERMANENT RESIDENT STATUS – Record of Landing, Permanent
OTHER – Work or Study Permit, etc.
Canadian Citizenship Card or Passport
Resident Card (front & back) or Confirmation of Permanent Residence
PERSONAL HEALTH NUMBER (PHN)
HAVE YOU HAD MSP COVERAGE PREVIOUSLY?
B
IF YES, PROVIDE
YES
NO (IF NO, GO TO “C”)
(MM / DD / YYYY)
(MM / DD / YYYY)
MOST RECENT MOVE TO CANADA
MOST RECENT MOVE TO BC
(IF WITHIN PAST 12 MONTHS)
HAVE YOU LIVED IN BC SINCE BIRTH?
C
PROVINCE OR COUNTRY MOVED FROM
PREVIOUS HEALTH NUMBER
YES
NO (IF YES, GO TO “D”)
IS THIS A PERMANENT MOVE?
YES
NO
HAVE YOU OR ANY FAMILY MEMBER BEEN OUTSIDE BC FOR MORE THAN 30 DAYS IN TOTAL DURING THE PAST 12 MONTHS?
YES
NO (IF NO, GO TO “E”)
D
DEPARTURE DATE (MM / DD / YYYY)
RETURN DATE (MM / DD / YYYY)
FAMILY MEMBER NAME, REASON FOR DEPARTURE AND LOCATION
WILL YOU OR ANY FAMILY MEMBER BE AWAY FROM BC
IF ANYONE LISTED IS AN ACTIVE MEMBER OF, OR HAS BEEN RELEASED FROM, THE CANADIAN FORCES,
FOR MORE THAN 30 DAYS IN TOTAL IN THE NEXT SIX MONTHS?
YES
NO
RCMP OR AN INSTITUTION, PLEASE PROVIDE THE DISCHARGE DATE:
IF YES, SEE RESIDENCY, PAGE 2.
(MM / DD / YYYY)
E
ARE YOU A FULL-TIME STUDENT?
YES
NO
IF YES, WILL YOU RESIDE IN BC ON COMPLETION OF YOUR STUDIES?
YES
NO
3 SPOUSE AND CHILD INFORMATION
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.
CHILD means a BC resident who is a child of a beneficiary or a person in respect of whom a beneficiary stands in the place of a parent, and who is a minor, does not have a spouse, and is supported by
the beneficiary.
PHOTOCOPIES OF CURRENT CITIZENSHIP/IMMIGRATION DOCUMENTS MUST BE ATTACHED. USE LEGAL NAMES WHEN COMPLETING THIS FORM.
SPOUSE LEGAL LAST NAME
SPOUSE LEGAL FIRST NAME
SPOUSE LEGAL SECOND NAME
GENDER
M
F
BIRTHDATE (MM / DD/ YYYY)
STATUS IN CANADA
CANADIAN CITIZEN – Canadian Birth Certificate,
HOLDER OF PERMANENT RESIDENT STATUS – Record of Landing, Permanent
OTHER – Work or
Canadian Citizenship Card or Passport
Resident Card (front & back) or Confirmation of Permanent Residence
Study Permit, etc.
PERSONAL HEALTH NUMBER (PHN)
HAS SPOUSE LIVED IN BC SINCE BIRTH?
MM / DD / YYYY
FROM (PROVINCE OR COUNTRY)
PREVIOUS HEALTH NUMBER
IF NO, MOST RECENT
YES
NO
MOVE TO BC
CHILD LEGAL LAST NAME
CHILD LEGAL FIRST NAME
CHILD LEGAL SECOND NAME
GENDER
M
F
BIRTHDATE (MM / DD/ YYYY)
STATUS IN CANADA
CANADIAN CITIZEN – Canadian Birth Certificate,
HOLDER OF PERMANENT RESIDENT STATUS – Record of Landing, Permanent
OTHER – Work or
Canadian Citizenship Card or Passport
Resident Card (front & back) or Confirmation of Permanent Residence
Study Permit, etc.
PERSONAL HEALTH NUMBER (PHN)
HAS CHILD LIVED IN BC SINCE BIRTH?
MM / DD / YYYY
FROM (PROVINCE OR COUNTRY)
PREVIOUS HEALTH NUMBER
IF NO, MOST RECENT
YES
MOVE TO BC
NO
Mailing Address: Health Insurance BC, Medical Services Plan, PO Box 9678 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
HLTH 102 V8 Rev. 2020/01/01
3 SPOUSE AND CHILD INFORMATION continued
CHILD LEGAL LAST NAME
CHILD LEGAL FIRST NAME
CHILD LEGAL SECOND NAME
GENDER
M
F
BIRTHDATE (MM / DD/ YYYY)
STATUS IN CANADA
CANADIAN CITIZEN – Canadian Birth Certificate,
HOLDER OF PERMANENT RESIDENT STATUS – Record of Landing, Permanent
OTHER – Work or
Canadian Citizenship Card or Passport
Resident Card (front & back) or Confirmation of Permanent Residence
Study Permit, etc.
PERSONAL HEALTH NUMBER (PHN)
HAS CHILD LIVED IN BC SINCE BIRTH?
MM / DD / YYYY
FROM (PROVINCE OR COUNTRY)
PREVIOUS HEALTH NUMBER
YES
IF NO, MOST RECENT
NO
MOVE TO BC
CHILD LEGAL LAST NAME
CHILD LEGAL FIRST NAME
CHILD LEGAL SECOND NAME
GENDER
M
F
BIRTHDATE (MM / DD/ YYYY)
STATUS IN CANADA
CANADIAN CITIZEN – Canadian Birth Certificate,
HOLDER OF PERMANENT RESIDENT STATUS – Record of Landing, Permanent
OTHER – Work or
Canadian Citizenship Card or Passport
Resident Card (front & back) or Confirmation of Permanent Residence
Study Permit, etc.
PERSONAL HEALTH NUMBER (PHN)
HAS CHILD LIVED IN BC SINCE BIRTH?
MM / DD / YYYY
FROM (PROVINCE OR COUNTRY)
PREVIOUS HEALTH NUMBER
YES
IF NO, MOST RECENT
NO
MOVE TO BC
IF YOU HAVE MORE CHILDREN, PLEASE CHECK BOX, ATTACH ADDITIONAL SHEET AND PROVIDE ALL INFORMATION
IF ANY OF THE CHILDREN ARE DEPENDENT POST-SECONDARY STUDENTS (SEE BELOW), PLEASE COMPLETE THE SECTION BELOW.
STUDENT LEGAL LAST NAME
STUDENT LEGAL FIRST NAME
STUDENT LEGAL SECOND NAME
DATE STUDIES WILL
IF SCHOOL IS OUTSIDE BC, ORIGINAL
SCHOOL NAME AND FULL ADDRESS
BE FINISHED (MM / DD / YYYY)
DEPARTURE DATE (MM / DD / YYYY)
TO ADD MORE DEPENDENT POST-SECONDARY STUDENTS, PLEASE CHECK BOX, ATTACH ADDITIONAL SHEET AND PROVIDE ALL INFORMATION
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.
4 SUPPLEMENTARY BENEFITS
MSP supplementary benefits provide partial payment for certain medical services obtained in British Columbia and may provide entitlement to the Healthy Kids program
and waiver of ambulance fees. Information about eligibility and how to apply can be found on Health Insurance BC's website at
www.hibc.gov.bc.ca
or on the
Application for Supplementary Benefits (HLTH 103).
5 AUTHORIZATION - MUST BE SIGNED BY APPLICANT, AND SPOUSE IF APPLICABLE (DO NOT CHANGE TEXT OF AUTHORIZATION BELOW)
I have received information about MSP and agree to abide by the terms and conditions of MSP. I understand that if a discrepancy exists between the information provided and
the legislation, the legislation will govern.
I authorize the Ministry of Health to collect my health information from practitioners who provide publicly funded health care service(s) to me under MSP and other publicly
funded health care programs, and I provide consent for those practitioners to disclose such information to the Ministry of Health for the purposes of assessing eligibility for,
and in regard to the administration of, MSP and other Ministry of Health publicly funded health care programs.
I declare that all information provided is true and I understand that the Ministry of Health 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.
SIGNATURE OF APPLICANT
SIGNATURE OF SPOUSE
DATE SIGNED (MM / DD / YYYY)
6 IMPORTANT INFORMATION
• IDENTIFICATION: You must send with your application: photocopies of documents that support the name and Canadian citizenship or immigration status for all persons listed.
Eligibility cannot be determined without this documentation. Canadian citizens and holders of permanent resident status (landed immigrants) returning from the USA may also be asked
to provide evidence of having established residence in BC and/or having abandoned their status in the USA. If any person is not enrolling under the name shown on his/her citizenship or
immigration document, please also submit a photocopy of a legal document (for example, a marriage or name change certificate) that indicates the name shown on this application.
• RESIDENCY: If you expect to leave the province for more than 30 days in total during the next 6 months, a letter outlining your planned dates of departure and return, destination and
the reason for your absence is required with this application. Failure to provide this information may affect eligibility for benefits.
• EFFECTIVE DATE OF BENEFITS: New and returning residents must complete a wait period before health care benefits begin. Generally, this period is the balance of the month of arrival
in BC, plus two months. If absences from Canada exceed a total of 30 days during the wait period, eligibility may be affected. Applications should be submitted immediately on arrival in
BC, not at the end of the wait period. If you apply late, the effective date of benefits will be determined by MSP.
• OUT-OF-PROVINCE STUDENTS: 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.
• CANCELLATION OF BENEFITS: If you will no longer be a resident of BC, you must notify Health Insurance BC that this is the case, and provide your date of departure from the province
and your new address.
• CHANGE OF NAME OR ADDRESS: Health Insurance BC must be notified immediately of any change of name or address.
• LEGISLATION: All information is subject to change in accordance with the Medicare Protection Act and Regulations and the Hospital Insurance Act and Regulations.
If a discrepancy exists between the information Health Insurance BC has provided on this application and the legislation, the legislation will prevail.
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 (FOIPPA) for the purposes of administration
of the Medical Services Plan. Information may be disclosed pursuant to section 33 of FOIPPA. If you have any questions about the collection and use of your personal information, please contact the Health Insurance
BC Chief Privacy Office at Health Insurance BC, Chief Privacy Office, PO Box 9035 STN PROV GOVT, Victoria, BC V8W 9E3 or call 604 683-7151 (Vancouver) or 1 800 663-7100 (toll-free).
HLTH 102 PAGE 2
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