Form HLTH103 "Medical Services Plan (Msp) Application for Supplementary Benefits" - British Columbia, Canada

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Download Form HLTH103 "Medical Services Plan (Msp) Application for Supplementary Benefits" - British Columbia, Canada

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SB
MEDICAL SERVICES PLAN (MSP)
A B C D
APPLICATION FOR
USE CAPITAL LETTERS ONLY
SUPPLEMENTARY BENEFITS
MSP supplementary benefits provide partial payment for certain medical services obtained in British Columbia and may provide access to other
income-based programs. For more information and to apply online, see www.gov.bc.ca/MSP/supplementarybenefits. To be assessed for supplementary benefits,
you must submit this form to Health Insurance BC (HIBC) with a copy of your most recent Notice of Assessment (NOA) or Notice of Reassessment (NORA) from
Canada Revenue Agency (CRA). Ensure the applicable name, tax year and tax return line 236/line 23600 (net income) are included.
APPLICANT INFORMATION
APPLICANT LEGAL LAST NAME
APPLICANT LEGAL FIRST NAME
APPLICANT LEGAL SECOND NAME
PERSONAL HEALTH NUMBER (PHN)
BIRTHDATE (MM / DD / YYYY)
DAYTIME TELEPHONE NUMBER
APT / UNIT
STREET NUMBER
STREET NAME
MAILING ADDRESS:
CITY
PROVINCE
POSTAL CODE
DECLARATION AND CONSENT - MUST BE SIGNED
Please read and sign. If you are married or living in a marriage-like relationship, your spouse must also sign.
If someone has Power of Attorney or another legal representation agreement and is signing on your behalf, include a copy of the agreement.
X
Mark (
) if you are married or living and cohabiting in a marriage-like relationship (even if your spouse is not covered under your MSP account) and include his/her
information (below) with your application.
X
Mark (
) if someone has Power of Attorney or another legal representation agreement and is signing on your behalf, and include a copy of the agreement with
your application.
I (applicant) am a resident of British Columbia as defined by the Medicare Protection Act.
I (applicant) have resided in Canada as a Canadian citizen or holder of permanent resident status (landed immigrant) for at least the last 12 months immediately preceding this application.
I am not exempt from liability to pay income tax by reason of any other Act.
I (applicant and, if applicable, spouse) hereby consent to the release of information from my income tax returns, and other taxpayer information, by the Canada Revenue Agency to the
Ministry of Health and/or Health Insurance BC. The information obtained will be relevant to and used for the purpose of determining and verifying my initial and ongoing entitlement to
the Supplementary Benefits Program under the Medicare Protection Act, and will not be disclosed to any other party. This authorization is valid for the taxation year prior to the signature of
this application, the year of the signature and for each subsequent consecutive taxation year for which supplementary benefits is requested. It may be revoked by sending a written notice
to Health Insurance BC.
APPLICANT SIGNATURE
SPOUSE SIGNATURE
DATE SIGNED (MM / DD / YYYY)
APPLICANT FIRST INITIAL AND LAST NAME
SPOUSE FIRST INITIAL AND LAST NAME
APPLICANT SOCIAL INSURANCE NUMBER
SPOUSE SOCIAL INSURANCE NUMBER
SPOUSE PERSONAL HEALTH NUMBER (PHN)
This form must be signed. We cannot accept unsigned forms. See page 2 for the Adjusted Net Income calculation worksheet.
MEDICAL SERVICES PLAN SUPPLEMENTARY BENEFITS INFORMATION
MSP enrolment must be complete for you (and your spouse, if applicable) to qualify for MSP supplementary benefits. To complete MSP enrolment, submit the MSP Application for
Enrolment form and 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.
Eligibility for supplementary benefits may be impacted if you do not file your income tax return with CRA each year; or if you do not update your MSP account if you marry or begin
living in a marriage-like relationship.
Income Verification - The signed declaration above allows the Ministry of Health and/or Health Insurance BC to verify your income information with CRA on an ongoing basis. In most
cases, you do not need to reapply for supplementary benefits as Health Insurance BC will continue to verify your income with CRA each year and will adjust your eligibility based on the
information received from CRA. In order to verify your income, the name and date of birth on your MSP account must match the information on file at CRA.
Fair PharmaCare - If you are already registered in Fair PharmaCare and have experienced a decrease in income, you might qualify for
increased Fair PharmaCare coverage. For more information or to register, visit
www.gov.bc.ca/pharmacare
or contact HIBC.
Mailing Address: Health Insurance BC, Medical Services Plan, PO Box 9677 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 103 V 3
Rev. 2020/03/24
SB
MEDICAL SERVICES PLAN (MSP)
A B C D
APPLICATION FOR
USE CAPITAL LETTERS ONLY
SUPPLEMENTARY BENEFITS
MSP supplementary benefits provide partial payment for certain medical services obtained in British Columbia and may provide access to other
income-based programs. For more information and to apply online, see www.gov.bc.ca/MSP/supplementarybenefits. To be assessed for supplementary benefits,
you must submit this form to Health Insurance BC (HIBC) with a copy of your most recent Notice of Assessment (NOA) or Notice of Reassessment (NORA) from
Canada Revenue Agency (CRA). Ensure the applicable name, tax year and tax return line 236/line 23600 (net income) are included.
APPLICANT INFORMATION
APPLICANT LEGAL LAST NAME
APPLICANT LEGAL FIRST NAME
APPLICANT LEGAL SECOND NAME
PERSONAL HEALTH NUMBER (PHN)
BIRTHDATE (MM / DD / YYYY)
DAYTIME TELEPHONE NUMBER
APT / UNIT
STREET NUMBER
STREET NAME
MAILING ADDRESS:
CITY
PROVINCE
POSTAL CODE
DECLARATION AND CONSENT - MUST BE SIGNED
Please read and sign. If you are married or living in a marriage-like relationship, your spouse must also sign.
If someone has Power of Attorney or another legal representation agreement and is signing on your behalf, include a copy of the agreement.
X
Mark (
) if you are married or living and cohabiting in a marriage-like relationship (even if your spouse is not covered under your MSP account) and include his/her
information (below) with your application.
X
Mark (
) if someone has Power of Attorney or another legal representation agreement and is signing on your behalf, and include a copy of the agreement with
your application.
I (applicant) am a resident of British Columbia as defined by the Medicare Protection Act.
I (applicant) have resided in Canada as a Canadian citizen or holder of permanent resident status (landed immigrant) for at least the last 12 months immediately preceding this application.
I am not exempt from liability to pay income tax by reason of any other Act.
I (applicant and, if applicable, spouse) hereby consent to the release of information from my income tax returns, and other taxpayer information, by the Canada Revenue Agency to the
Ministry of Health and/or Health Insurance BC. The information obtained will be relevant to and used for the purpose of determining and verifying my initial and ongoing entitlement to
the Supplementary Benefits Program under the Medicare Protection Act, and will not be disclosed to any other party. This authorization is valid for the taxation year prior to the signature of
this application, the year of the signature and for each subsequent consecutive taxation year for which supplementary benefits is requested. It may be revoked by sending a written notice
to Health Insurance BC.
APPLICANT SIGNATURE
SPOUSE SIGNATURE
DATE SIGNED (MM / DD / YYYY)
APPLICANT FIRST INITIAL AND LAST NAME
SPOUSE FIRST INITIAL AND LAST NAME
APPLICANT SOCIAL INSURANCE NUMBER
SPOUSE SOCIAL INSURANCE NUMBER
SPOUSE PERSONAL HEALTH NUMBER (PHN)
This form must be signed. We cannot accept unsigned forms. See page 2 for the Adjusted Net Income calculation worksheet.
MEDICAL SERVICES PLAN SUPPLEMENTARY BENEFITS INFORMATION
MSP enrolment must be complete for you (and your spouse, if applicable) to qualify for MSP supplementary benefits. To complete MSP enrolment, submit the MSP Application for
Enrolment form and 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.
Eligibility for supplementary benefits may be impacted if you do not file your income tax return with CRA each year; or if you do not update your MSP account if you marry or begin
living in a marriage-like relationship.
Income Verification - The signed declaration above allows the Ministry of Health and/or Health Insurance BC to verify your income information with CRA on an ongoing basis. In most
cases, you do not need to reapply for supplementary benefits as Health Insurance BC will continue to verify your income with CRA each year and will adjust your eligibility based on the
information received from CRA. In order to verify your income, the name and date of birth on your MSP account must match the information on file at CRA.
Fair PharmaCare - If you are already registered in Fair PharmaCare and have experienced a decrease in income, you might qualify for
increased Fair PharmaCare coverage. For more information or to register, visit
www.gov.bc.ca/pharmacare
or contact HIBC.
Mailing Address: Health Insurance BC, Medical Services Plan, PO Box 9677 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 103 V 3
Rev. 2020/03/24
FINANCIAL INFORMATION
Use the latest NOA/NORA available
TAX YEAR
from CRA.
Include a photocopy of your Notice of Assessment (NOA) or Notice of Reassessment (NORA) (and your
2 0
spouse’s, if applicable) for the tax year indicated. This information is from my NOA/NORA for the tax year:
NET INCOME
Net income is found on line 236/
line 23600 of the CRA Notice
,
1 Enter your net income (from your Notice of Assessment or Notice of Reassessment)
$
1
of Assessment or Notice of
Note: If net income is a negative number (e.g. – $2,300.00), enter 0
Reassessment.
,
2 Enter the net income of your spouse
$
2
Note: If net income is a negative number (e.g. – $2,300.00), enter 0
,
3 TOTAL NET INCOME (add lines 1 and 2)
$
3
DEDUCTIONS ALLOWED BY THE MEDICAL SERVICES PLAN (MSP)
UNIVERSAL CHILD CARE BENEFIT
If your NOA or NORA indicates a
,
4 SPOUSE - if you are married or living in a marriage-like relationship, claim $3,000
$
4
retroactive Universal Child Care
Benefit (UCCB) payment (line 117/
,
5 If you are 65 or older, claim $3,000
$
5
line 11700), HIBC will assess a
deduction to your Adjusted Net
Income.
,
6 If your spouse is 65 or older, claim $3,000
$
6
CHILDREN
,
Claim $3,000 for each minor (under
CHILDREN
x $3,000 =
$
19 years of age) or dependent post-
number of minors/dependent post-secondary students
secondary student (19-24 years of
minus one half of the child care expenses
age; may include a student enrolled
claimed on your (or your spouse’s)
in full-time studies at a trade school,
income tax return (1/2 of line 214/line 21400)
– $
,
technical school or high school)
included under your MSP coverage.
,
,
7 Difference (if a negative number, enter 0) =
$
➮ $
7
DISABILITY
If you claimed a disability on your
income tax return for yourself, or
,
8 DISABILITY
x $3,000 =
$
8
your spouse, minor or dependent
number of disabled individuals on account
post-secondary student included
Note: Provide a letter from CRA showing eligibility for the applicable tax year.
under your MSP coverage, claim
$3,000 for each disabled person.
9 Registered Disability Savings Plan income reported on your
If you claimed attendant or nursing
(and/or your spouse’s) income tax return (line 125/line12500)
,
$
9
home expenses in place of disability,
enclose photocopies of receipts.
,
10 TOTAL DEDUCTIONS (add lines 4 to 9)
$
10
ADJUSTED NET INCOME
ADJUSTED NET INCOME
is net income from your
Notice of Assessment or Notice
,
11 ADJUSTED NET INCOME (subtract line 10 from line 3)
$
11
of Reassessment minus above
deductions allowed by MSP.
Note: If this amount is $42,000 or less, you may be eligible for supplementary benefits.
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 for the
purposes of administration of the Medical Services Plan. 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 103 PAGE 2
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