Form HLTH1917 "Medical Services Plan (Msp) Pay Reciprocal Practitioner Claim" - British Columbia, Canada

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Download Form HLTH1917 "Medical Services Plan (Msp) Pay Reciprocal Practitioner Claim" - British Columbia, Canada

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medical services plan (msp)
pay reciprocal practitioner claim
PLEASE USE
A B C D
claims must be submitted within 90 days
CAPITAL LETTERS ONLY
patient inFormation
PROVINCE/
TERRITORY
REGISTRATION NUMBER
PATIENT LEGAL FIRST NAME
SECOND NAME INITIAL
PATIENT LEGAL LAST NAME
CORRESPONDENCE
SUBMISSION
GENDER
PATIENT BIRTHDATE (MM / DD / YYYY)
MVA RELATED? IF YES, MVA CLAIM NUMBER
ATTACHED
CODE
M
F
YES
APT / UNIT
STREET NUMBER
STREET NAME
CITY
PROVINCE
POSTAL CODE
service(s)
LOC.
TIME
OF
DATE OF SERVICE
NO. OF
CALLED
RENDERED
MONTH
DAY
YEAR
SERVICES
S.C.C.
FEE ITEM
AMOUNT BILLED
START
FINISH
DIAGNOSTIC CODE
SERV.
hospital visits
LOC.
NO. OF
DATE OF SERVICE
OF
MONTH
DAY FROM - TO
YEAR
SERVICES
S.C.C.
FEE ITEM
AMOUNT BILLED
DIAGNOSTIC CODE
SERV.
DIAGNOSIS OR AREA OF TREATMENT
practitioner inFormation
FIRST NAME
PRACTITIONER LAST NAME OR CLINIC NAME
INITIAL
PRACTITIONER SIGNATURE
PAYMENT NUMBER
PRACTITIONER NUMBER
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 1917 V1 Rev. 2010/09/21
PRINT
RESET
pr
medical services plan (msp)
pay reciprocal practitioner claim
PLEASE USE
A B C D
claims must be submitted within 90 days
CAPITAL LETTERS ONLY
patient inFormation
PROVINCE/
TERRITORY
REGISTRATION NUMBER
PATIENT LEGAL FIRST NAME
SECOND NAME INITIAL
PATIENT LEGAL LAST NAME
CORRESPONDENCE
SUBMISSION
GENDER
PATIENT BIRTHDATE (MM / DD / YYYY)
MVA RELATED? IF YES, MVA CLAIM NUMBER
ATTACHED
CODE
M
F
YES
APT / UNIT
STREET NUMBER
STREET NAME
CITY
PROVINCE
POSTAL CODE
service(s)
LOC.
TIME
OF
DATE OF SERVICE
NO. OF
CALLED
RENDERED
MONTH
DAY
YEAR
SERVICES
S.C.C.
FEE ITEM
AMOUNT BILLED
START
FINISH
DIAGNOSTIC CODE
SERV.
hospital visits
LOC.
NO. OF
DATE OF SERVICE
OF
MONTH
DAY FROM - TO
YEAR
SERVICES
S.C.C.
FEE ITEM
AMOUNT BILLED
DIAGNOSTIC CODE
SERV.
DIAGNOSIS OR AREA OF TREATMENT
practitioner inFormation
FIRST NAME
PRACTITIONER LAST NAME OR CLINIC NAME
INITIAL
PRACTITIONER SIGNATURE
PAYMENT NUMBER
PRACTITIONER NUMBER
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 1917 V1 Rev. 2010/09/21
PRINT
RESET