Form HLTH217 "Medical Services Plan (Msp) Group Coverage Cancellation" - British Columbia, Canada

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Download Form HLTH217 "Medical Services Plan (Msp) Group Coverage Cancellation" - British Columbia, Canada

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MEDICAL SERVICES PLAN (MSP)
GROUP COVERAGE CANCELLATION
TO CANCEL ENTIRE CONTRACT ONLY
1 2 3 4 A B C D
PLEASE PRINT IN CAPITAL LETTERS ONLY:
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
(FOIPPA) for the purposes of administration of the Medical Services Plan. Information may be disclosed pursuant to section 33 of FOIPPA. 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).
TO BE COMPLETED BY COMPENSATION SPECIALIST / PAY OFFICE / PENSION OFFICE
LEGAL LAST NAME
LEGAL FIRST NAME
LEGAL SECOND NAME
MAILING ADDRESS
APT / UNIT
STREET NUMBER
STREET NAME
CITY
PROV
POSTAL CODE
BIRTHDATE (MM / DD / YYYY)
EMPLOYEE / PENSION NUMBER
GROUP NUMBER
PERSONAL HEALTH NUMBER (PHN)
MSP ACCOUNT NUMBER
To cancel coverage for employee / pensioner and all dependants
Group coverage is cancelled on the last day of the month unless it is being cancelled as of the effective date. Please refer to your Group Procedure Guide for more information.
REASON FOR CANCELLATION
TERMINATED
OTHER COVERAGE
DECEASED
AND/OR
(MM / DD / YYYY)
(MM / DD / YYYY)
MOVED OUT OF PROVINCE
MOVED OUT OF COUNTRY
(PROVIDE DATE OF MOVE)
(PROVIDE DATE OF MOVE)
(MM / DD / YYYY)
GROUP COVERAGE WILL
CEASE ON THIS DATE
AUTHORIZATION - THIS SECTION MUST BE COMPLETED
ADDRESS OF PAYROLL / PENSION OFFICE
POSTAL CODE
AREA CODE AND PHONE NUMBER
LOCAL
DATE AUTHORIZED (MM / DD / YYYY)
AUTHORIZATION NAME OR STAMP
WHEN THIS FORM HAS BEEN COMPLETED, PLEASE FORWARD TO HEALTH INSURANCE BC
INCOMPLETE OR UNAUTHORIZED FORMS WILL BE RETURNED
Mailing Address: Health Insurance BC, Medical Services Plan, PO Box 9680 Stn Prov Govt, Victoria BC V8W 9P7
Tel: (Lower Mainland) 604 683-7520, (Rest of BC) 1 877 955-5656 Web: www.hibc.gov.bc.ca
HLTH 217 V4 Rev. 2019/07/03
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MEDICAL SERVICES PLAN (MSP)
GROUP COVERAGE CANCELLATION
TO CANCEL ENTIRE CONTRACT ONLY
1 2 3 4 A B C D
PLEASE PRINT IN CAPITAL LETTERS ONLY:
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
(FOIPPA) for the purposes of administration of the Medical Services Plan. Information may be disclosed pursuant to section 33 of FOIPPA. 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).
TO BE COMPLETED BY COMPENSATION SPECIALIST / PAY OFFICE / PENSION OFFICE
LEGAL LAST NAME
LEGAL FIRST NAME
LEGAL SECOND NAME
MAILING ADDRESS
APT / UNIT
STREET NUMBER
STREET NAME
CITY
PROV
POSTAL CODE
BIRTHDATE (MM / DD / YYYY)
EMPLOYEE / PENSION NUMBER
GROUP NUMBER
PERSONAL HEALTH NUMBER (PHN)
MSP ACCOUNT NUMBER
To cancel coverage for employee / pensioner and all dependants
Group coverage is cancelled on the last day of the month unless it is being cancelled as of the effective date. Please refer to your Group Procedure Guide for more information.
REASON FOR CANCELLATION
TERMINATED
OTHER COVERAGE
DECEASED
AND/OR
(MM / DD / YYYY)
(MM / DD / YYYY)
MOVED OUT OF PROVINCE
MOVED OUT OF COUNTRY
(PROVIDE DATE OF MOVE)
(PROVIDE DATE OF MOVE)
(MM / DD / YYYY)
GROUP COVERAGE WILL
CEASE ON THIS DATE
AUTHORIZATION - THIS SECTION MUST BE COMPLETED
ADDRESS OF PAYROLL / PENSION OFFICE
POSTAL CODE
AREA CODE AND PHONE NUMBER
LOCAL
DATE AUTHORIZED (MM / DD / YYYY)
AUTHORIZATION NAME OR STAMP
WHEN THIS FORM HAS BEEN COMPLETED, PLEASE FORWARD TO HEALTH INSURANCE BC
INCOMPLETE OR UNAUTHORIZED FORMS WILL BE RETURNED
Mailing Address: Health Insurance BC, Medical Services Plan, PO Box 9680 Stn Prov Govt, Victoria BC V8W 9P7
Tel: (Lower Mainland) 604 683-7520, (Rest of BC) 1 877 955-5656 Web: www.hibc.gov.bc.ca
HLTH 217 V4 Rev. 2019/07/03
PRINT
RESET