Form HLTH1918 "Medical Services Plan (Msp) Pay Dentist Claim" - British Columbia, Canada

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Download Form HLTH1918 "Medical Services Plan (Msp) Pay Dentist Claim" - British Columbia, Canada

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pd
medical services plan (msp)
pay dentist claim
PLEASE USE
A B C D
claims must be submitted within 90 days
CAPITAL LETTERS ONLY
patient inFOrmatiOn
PERSONAL HEALTH NUMBER (PHN)
DEPENDANT
PATIENT LEGAL FIRST NAME
SECOND NAME INITIAL
PATIENT LEGAL LAST NAME
CORRESPONDENCE
SUBMISSION
PATIENT BIRTHDATE (MM / YYYY)
MVA RELATED? IF YES, MVA CLAIM NUMBER
ATTACHED
CODE
PLAN REFERENCE NUMBER OF ORIGINAL CLAIM
YES
service(s)
TIME
LOC.
DATE OF SERVICE
NO. OF
CALLED
RENDERED
OF
S.C.C.
FEE ITEM
AMOUNT BILLED
DIAGNOSTIC CODE
SERV.
MONTH
DAY
YEAR
SERVICES
START
FINISH
X
PLEASE IDENTIFY TEETH ACCORDING TO CHARTS (
)
UR
55
54
53
52
51
61
62
63
64
65
UL
PRIMARY
LR
85
84
83
82
81
71
72
73
74
75
LL
UR
18
17
16
15
14
13
12
11
21
22
23
24
25
26
27
28
UL
PERMANENT
LR
48
47
46
45
44
43
42
41
31
32
33
34
35
36
37
38
LL
NOTES
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 1918 V2 Rev. 2012/08/16
PRINT
RESET
pd
medical services plan (msp)
pay dentist claim
PLEASE USE
A B C D
claims must be submitted within 90 days
CAPITAL LETTERS ONLY
patient inFOrmatiOn
PERSONAL HEALTH NUMBER (PHN)
DEPENDANT
PATIENT LEGAL FIRST NAME
SECOND NAME INITIAL
PATIENT LEGAL LAST NAME
CORRESPONDENCE
SUBMISSION
PATIENT BIRTHDATE (MM / YYYY)
MVA RELATED? IF YES, MVA CLAIM NUMBER
ATTACHED
CODE
PLAN REFERENCE NUMBER OF ORIGINAL CLAIM
YES
service(s)
TIME
LOC.
DATE OF SERVICE
NO. OF
CALLED
RENDERED
OF
S.C.C.
FEE ITEM
AMOUNT BILLED
DIAGNOSTIC CODE
SERV.
MONTH
DAY
YEAR
SERVICES
START
FINISH
X
PLEASE IDENTIFY TEETH ACCORDING TO CHARTS (
)
UR
55
54
53
52
51
61
62
63
64
65
UL
PRIMARY
LR
85
84
83
82
81
71
72
73
74
75
LL
UR
18
17
16
15
14
13
12
11
21
22
23
24
25
26
27
28
UL
PERMANENT
LR
48
47
46
45
44
43
42
41
31
32
33
34
35
36
37
38
LL
NOTES
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 1918 V2 Rev. 2012/08/16
PRINT
RESET