Form HLTH1916 "Medical Services Plan (Msp) Pay Patient Claim" - British Columbia, Canada

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Download Form HLTH1916 "Medical Services Plan (Msp) Pay Patient Claim" - British Columbia, Canada

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pp
medical services plan (msp)
pay paTienT claim
A B C D
claims musT be submiTTed wiThin 90 days. please dO nOT Fax This FOrm.
USE CAPITAL
To ensure this claim is processed, please follow instructions on page 2.
LETTERS ONLY
paTienT inFOrmaTiOn
PERSONAL HEALTH NUMBER (PHN)
DEPENDANT
PATIENT LEGAL FIRST NAME
SECOND NAME INITIAL
PATIENT LEGAL LAST NAME
PATIENT BIRTHDATE (MM / YYYY)
MVA RELATED? IF YES, MVA CLAIM NUMBER
PATIENT OR PARENT/GUARDIAN SIGNATURE
YES
CORRESPONDENCE
SUBMISSION
ATTACHED
CODE
PLAN REFERENCE NUMBER OF ORIGINAL CLAIM
service(s)
TIME
LOC.
DATE OF SERVICE
NO. OF
CALLED
RENDERED
OF
MONTH
DAY
YEAR
SERVICES
S.C.C.
FEE ITEM
AMOUNT BILLED
START
FINISH
DIAGNOSTIC CODE
SERV.
DIAGNOSIS OR AREA OF TREATMENT
paymenT mailinG address
WHOSE ADDRESS IS THIS?
PRACTITIONER
PATIENT
APT / UNIT
STREET NUMBER
STREET NAME
CITY
PROVINCE
POSTAL CODE
B C
pracTiTiOner inFOrmaTiOn
FIRST NAME
PRACTITIONER LAST NAME OR CLINIC NAME
INITIAL
PRACTITIONER SIGNATURE
PAYMENT NUMBER
PRACTITIONER NUMBER
SPEC. CODE
REFERRED BY
PRACTITIONER NUMBER
REFERRED BY (PRACTITIONER LAST NAME)
FIRST NAME INITIAL
REFERRED TO
PRACTITIONER NUMBER
REFERRED TO (PRACTITIONER LAST NAME)
FIRST NAME INITIAL
Mailing Address: Health Insurance BC, Medical Services Plan, PO Box 9689 Stn Prov Govt, Victoria BC V8W 9P8
Web: www.hibc.gov.bc.ca
Tel: (Lower Mainland) 604 456-6950, (Rest of BC) 1 866 456-6950
HLTH 1916 V3 Rev. 2012/08/16
PRINT
RESET
pp
medical services plan (msp)
pay paTienT claim
A B C D
claims musT be submiTTed wiThin 90 days. please dO nOT Fax This FOrm.
USE CAPITAL
To ensure this claim is processed, please follow instructions on page 2.
LETTERS ONLY
paTienT inFOrmaTiOn
PERSONAL HEALTH NUMBER (PHN)
DEPENDANT
PATIENT LEGAL FIRST NAME
SECOND NAME INITIAL
PATIENT LEGAL LAST NAME
PATIENT BIRTHDATE (MM / YYYY)
MVA RELATED? IF YES, MVA CLAIM NUMBER
PATIENT OR PARENT/GUARDIAN SIGNATURE
YES
CORRESPONDENCE
SUBMISSION
ATTACHED
CODE
PLAN REFERENCE NUMBER OF ORIGINAL CLAIM
service(s)
TIME
LOC.
DATE OF SERVICE
NO. OF
CALLED
RENDERED
OF
MONTH
DAY
YEAR
SERVICES
S.C.C.
FEE ITEM
AMOUNT BILLED
START
FINISH
DIAGNOSTIC CODE
SERV.
DIAGNOSIS OR AREA OF TREATMENT
paymenT mailinG address
WHOSE ADDRESS IS THIS?
PRACTITIONER
PATIENT
APT / UNIT
STREET NUMBER
STREET NAME
CITY
PROVINCE
POSTAL CODE
B C
pracTiTiOner inFOrmaTiOn
FIRST NAME
PRACTITIONER LAST NAME OR CLINIC NAME
INITIAL
PRACTITIONER SIGNATURE
PAYMENT NUMBER
PRACTITIONER NUMBER
SPEC. CODE
REFERRED BY
PRACTITIONER NUMBER
REFERRED BY (PRACTITIONER LAST NAME)
FIRST NAME INITIAL
REFERRED TO
PRACTITIONER NUMBER
REFERRED TO (PRACTITIONER LAST NAME)
FIRST NAME INITIAL
Mailing Address: Health Insurance BC, Medical Services Plan, PO Box 9689 Stn Prov Govt, Victoria BC V8W 9P8
Web: www.hibc.gov.bc.ca
Tel: (Lower Mainland) 604 456-6950, (Rest of BC) 1 866 456-6950
HLTH 1916 V3 Rev. 2012/08/16
PRINT
RESET
insTrucTiOns FOr cOmpleTinG and submiTTinG This claim
Only the following claim types can be submitted by mail using this downloadable “fill, print and mail” Claim Form:
• Pay patient claims for opted-out practitioners
• Correctional facilities claims
• Dental claims
• Reciprocal claims
• Claims for patients covered under the Critical Care Coverage Program
If a practitioner can demonstrate that they reside in a community without internet access or that obtaining internet
access will cause significant financial hardship, they can submit their claims via mail using a Claim Form. To receive
paper copies of the form, practitioners must request an exemption in writing demonstrating that obtaining internet
access will cause significant hardship. Requests for an exemption should be sent to Health Insurance BC at the
address listed at the bottom of page 1. All other claims must be submitted electronically.
Mail the completed form to the address that appears at the bottom of page 1 of this form. please do not include
your receipts(s) with this claim.
claims must be submitted to the medical services plan (msp) within 90 days of the date of service.
paTienT and paymenT inFOrmaTiOn
In order for MSP to process this claim, the following areas must be completed:
• patient’s PERSONAL HEALTH NUMBER
• PATIENT’S LEGAL FIRST NAME, first initial of SECOND NAME (if you legally have a second name),
and LAST NAME
• PATIENT BIRTHDATE (month and year)
• PATIENT SIGNATURE (or signature of parent/guardian)
• PAYMENT MAILING ADDRESS - ensure the address inserted is the address to which payment should be made
pracTiTiOner and services inFOrmaTiOn
also, please ensure that your practitioner has completed the areas listed below on your behalf. if these areas
are not complete, please return the form to your practitioner, as we will be unable to process your claim.
• DATE OF SERVICE
• NO. (number) OF SERVICES
• S.C.C. (service clarification code)—if applicable
• FEE ITEM
• AMOUNT BILLED
• DIAGNOSTIC CODE
• PRACTITIONER LAST NAME OR CLINIC NAME
• PRACTITIONER SIGNATURE
• PAYMENT NUMBER
• PRACTITIONER NUMBER
Please allow 4 to 6 weeks for processing claims for routine medical services. Specialist services may require
additional processing time.
mOvinG?
When you move, please go to www.hibc.gov.bc.ca, choose “B.C. Residents” and click on
“Change Your Address” to immediately update your address. Or call us – from the Lower Mainland at 604-683-7151 or
from the rest of BC at 1-800-663-7100.
HLTH 1916 PAGE 2
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