Form HLTH2839 "Medical Services Plan (Msp) Orthodontic Program Eligibility" - British Columbia, Canada

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medical services plan (msp)
orthodontic program eligibility
USE CAPITAL
A B C D
LETTERS ONLY
This form is to request funding assistance for a child with a confirmed medical diagnosis of the following conditions:
• Cleft lip and/or palate
• Syndromic craniofacial anomaly
The child must also:
• Be a Canadian citizen or permanent landed immigrant and a resident of BC;
• Have active Medical Services Plan (MSP) coverage;
• Not be older than 19 years of age at start of dental consultation/treatment; and,
• Maintain good oral hygiene throughout the treatment period.
Note: Eligibility for program funding ends on the day of the patient’s 21st birthday.
1. eligible patient inFormation
PATIENT LEGAL LAST NAME
PATIENT LEGAL FIRST NAME
PATIENT LEGAL SECOND NAME
PERSONAL HEALTH NUMBER
BIRTHDATE (MM / DD / YYYY)
PARENT/LEGAL GUARDIAN LEGAL LAST NAME
PARENT/LEGAL GUARDIAN LEGAL FIRST NAME
DAYTIME TELEPHONE NUMBER
ADDRESS
PROV
POSTAL CODE
NAME OF PRIVATE DENTAL PLAN
LIST ORTHODONTIA BENEFITS
2. orthodontist inFormation
NAME
TELEPHONE (INCLUDE AREA CODE)
FAX (INCLUDE AREA CODE)
MSP PRACTITIONER NUMBER
ADDRESS
PROV
POSTAL CODE
3. medical diagnosis type
REQUEST FOR CLEFT LIP/PALATE (SEE SECTION 4)
REQUEST FOR SYNDROMIC CRANIOFACIAL (SEE SECTION 5)
4. cleFt lip/palate (diagnostic code 749.2)
PHASE OF TREATMENT (AS PER APPROVED PAYMENT SCHEDULE)
INITIAL EXPANSION AND ALIGNMENT
FULL ALIGNMENT AND RETENTION
NEONATAL
SPEECH OBTURATOR
SIMPLE
COMPLEX
SEVERE
CLASS I
CLASS II
CLASS III
SIMPLE
COMPLEX
SEVERE
DESCRIPTION OF TREATMENT AND APPLIANCES (PLEASE DESCRIBE TREATMENT PLAN)
DATE OF INITIAL EXAMINATION (MM / DD / YYYY)
DATE OF COMMENCEMENT OF TREATMENT (MM / DD / YYYY)
ESTIMATED DATE RETENTION COMPLETED (MM / DD / YYYY)
Mailing Address: Medical Services Plan, Orthodontic Program, PO Box 9641 Stn Prov Govt, Victoria BC V8W 9P1
Tel: 250 405-3742, Fax: 250 405-3588
Web: www.hibc.gov.bc.ca
HLTH 2839 Rev. 2012/11/09
medical services plan (msp)
orthodontic program eligibility
USE CAPITAL
A B C D
LETTERS ONLY
This form is to request funding assistance for a child with a confirmed medical diagnosis of the following conditions:
• Cleft lip and/or palate
• Syndromic craniofacial anomaly
The child must also:
• Be a Canadian citizen or permanent landed immigrant and a resident of BC;
• Have active Medical Services Plan (MSP) coverage;
• Not be older than 19 years of age at start of dental consultation/treatment; and,
• Maintain good oral hygiene throughout the treatment period.
Note: Eligibility for program funding ends on the day of the patient’s 21st birthday.
1. eligible patient inFormation
PATIENT LEGAL LAST NAME
PATIENT LEGAL FIRST NAME
PATIENT LEGAL SECOND NAME
PERSONAL HEALTH NUMBER
BIRTHDATE (MM / DD / YYYY)
PARENT/LEGAL GUARDIAN LEGAL LAST NAME
PARENT/LEGAL GUARDIAN LEGAL FIRST NAME
DAYTIME TELEPHONE NUMBER
ADDRESS
PROV
POSTAL CODE
NAME OF PRIVATE DENTAL PLAN
LIST ORTHODONTIA BENEFITS
2. orthodontist inFormation
NAME
TELEPHONE (INCLUDE AREA CODE)
FAX (INCLUDE AREA CODE)
MSP PRACTITIONER NUMBER
ADDRESS
PROV
POSTAL CODE
3. medical diagnosis type
REQUEST FOR CLEFT LIP/PALATE (SEE SECTION 4)
REQUEST FOR SYNDROMIC CRANIOFACIAL (SEE SECTION 5)
4. cleFt lip/palate (diagnostic code 749.2)
PHASE OF TREATMENT (AS PER APPROVED PAYMENT SCHEDULE)
INITIAL EXPANSION AND ALIGNMENT
FULL ALIGNMENT AND RETENTION
NEONATAL
SPEECH OBTURATOR
SIMPLE
COMPLEX
SEVERE
CLASS I
CLASS II
CLASS III
SIMPLE
COMPLEX
SEVERE
DESCRIPTION OF TREATMENT AND APPLIANCES (PLEASE DESCRIBE TREATMENT PLAN)
DATE OF INITIAL EXAMINATION (MM / DD / YYYY)
DATE OF COMMENCEMENT OF TREATMENT (MM / DD / YYYY)
ESTIMATED DATE RETENTION COMPLETED (MM / DD / YYYY)
Mailing Address: Medical Services Plan, Orthodontic Program, PO Box 9641 Stn Prov Govt, Victoria BC V8W 9P1
Tel: 250 405-3742, Fax: 250 405-3588
Web: www.hibc.gov.bc.ca
HLTH 2839 Rev. 2012/11/09
5. congenital cranioFacial (diagnostic code 524.2) - orthognathic surgery required
phase oF treatment applying For at this time (as per individUal consideration). inclUde conFirmation letter From children’s hospital.
DECIDUOUS PHASE
MIXED DEFINITION PHASE
PERMANENT DEFINITION PHASE
SIMPLE
COMPLEX
SEVERE
SIMPLE
COMPLEX
SEVERE
SIMPLE
COMPLEX
SEVERE
DESCRIPTION OF TREATMENT AND APPLIANCES (PLEASE DESCRIBE TREATMENT PLAN)
DATE OF INITIAL EXAMINATION (MM / DD / YYYY)
DATE OF COMMENCEMENT OF TREATMENT (MM / DD / YYYY)
ESTIMATED DATE RETENTION COMPLETED (MM / DD / YYYY)
HAS ORTHOGNATHIC SURGERY BEEN PERFORMED?
IF YES, LIST SURGICAL PROCEDURES PERFORMED
YES
NO
NAME OF SURGEON, IF KNOWN
DATE, IF KNOWN (MM / DD / YYYY)
WILL ORTHOGNATHIC SURGERY BE REQUIRED IN FUTURE?
IF YES, LIST PROPOSED SURGERY
YES
NO
NAME OF SURGEON, IF KNOWN
DATE, IF KNOWN (MM / DD / YYYY)
HAS THE SURGICAL CONSULTATION TAKEN PLACE?
YES
NO
6. Financial arrangements
the current payment schedule is online at www.health.gov.bc.ca/msp/infoprac/dentists.html. this section mUst be filled out in order to be eligible for
funding assistance. Please do not send x-rays and/or models unless requested by MSP.
a. preparatory procedUres (Indicate appropriate fee item (✔) and fee amount from approved schedule)
CLEFT PALATE SCHEDULE
CRANIOFACIAL SCHEDULE
FEE AMOUNT
INITIAL EXAMINATION
3970
3978
3952
$
DIAGNOSTIC PHASE
3971
3979
3953
$
CASE ANALYSIS AND CONSULTATION
3972
3980
3954
$
sUbtotal
$
b. treatment procedUres (Select appropriate fee from approved schedule)
CLEFT PALATE SCHEDULE
CRANIOFACIAL SCHEDULE I.C.
MISC. FEE ITEM
FEE AMOUNT
$
$
$
$
sUbtotal
$
total Fee
$
7. practitioner signatUre
Personal information on this form is collected under the authority of the
Medicare Protection Act and will be used to determine if the procedure(s)
PRACTITIONER SIGNATURE
performed is a benefit of the Medical Services Plan and to determine the
amount payable in accordance with the Act, regulations and appropriate
payment schedules. This information is protected from unauthorized
use and disclosure in accordance with the Freedom of Information and
Protection of Privacy Act and may be disclosed only as provided by that Act.
If you have any questions about the collection of information,
DATE SIGNED (MM / DD / YYYY)
contact Health Insurance BC: (Lower Mainland) 604 456-6950,
(Rest of BC) 1 866 456-6950.
HLTH 2839 PAGE 2
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