Form Hlth 170 PDF Details

Navigating the intricacies of the healthcare system in British Columbia can seem daunting, but understanding the HLTH 170 form is a great place to start for those looking to update their Medical Services Plan (MSP) Group information. This comprehensive form serves a variety of purposes, from updating the account holder's personal information to adding or removing a spouse or child from the plan. It is required by law for residents of BC, ensuring that all family members residing in the province are enrolled. Not only does this document facilitate changes to the account holder's name or address but it also covers adjustments needed for a spouse or child's details, requiring legal documents for verification of such changes. It's critical for residents to understand that this form must be completed with care, as it involves the collection of personal information under the authority of the Medicare Protection Act, meaning accurate and complete responses are crucial. The authorization section highlights the importance of honesty in the submission of this form, as it may be used to assess eligibility for other Ministry of Health programs. Whether it's a simple address change, adding a new family member, or correcting existing information, the HLTH 170 form is integral to maintaining your and your family's health service coverage up-to-date, ensuring you can enjoy the benefits of the province's healthcare system without hiccups.

QuestionAnswer
Form NameForm Hlth 170
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesBIRTHDATE, 9P8, 2012, V8W

Form Preview Example

MEDICAL SERVICES PLAN (MSP)

GROUP CHANGE REQUEST

GC

A B C D

PLEASE USE

CAPITAL LETTERS ONLY

Residents of BC are required, by law, to enrol themselves and to enrol their spouse and children who are residents of BC.

RESIDENT means a person who is a citizen of Canada or is lawfully admitted to Canada for permanent residence, who makes his or her home in British Columbia, and is physically present in British Columbia for at least 6 months in a calendar year, or a shorter prescribed period, and includes a person who is deemed under the regulations to be a resident but does not include a tourist or visitor to British Columbia.

1 CHANGE REQUEST

I AM SUBMITTING THIS FORM TO (PLEASE MARK ( X

) ALL BOXES THAT APPLY):

CHANGE/CORRECT ACCOUNT HOLDER’S INFORMATION – Complete sections 2 (with new/correct information) and 4, and take this form to your Group Administrator to authorize (section 5). Legal documents are required for MSP to confirm a change or correction. For example, provide a photocopy of your proof of Status in Canada (see examples on page 2) or marriage/change of name certificate.

CHANGE ADDRESS INFORMATION – Complete sections 2, 3, 4 and take this form to your Group Administrator to authorize (section 5).

ADD, REMOVE OR CHANGE/CORRECT INFORMATION FOR A SPOUSE – On page 2, complete section 7 and, if you are adding a spouse, section 9. On this page complete sections 2, 4 and take this form to your Group Administrator to authorize (section 5). Provide photocopies of all applicable documents as explained in section 7 on page 2.

ADD, REMOVE OR CHANGE/CORRECT INFORMATION FOR A CHILD – On page 2, complete section 8 and, if you are adding a child, section 9. On this page complete sections 2, 4 and take this form to your Group Administrator to authorize (section 5). Provide photocopies of all applicable documents as explained in section 8 on page 2.

CHANGE GROUP PLAN INFORMATION (GROUP ADMINISTRATOR USE ONLY) – Complete sections 2, 5 and 6.

2ACCOUNT HOLDER INFORMATION – THIS SECTION MUST BE COMPLETED

ACCOUNT HOLDER LEGAL LAST NAME

ACCOUNT HOLDER LEGAL FIRST NAME

 

ACCOUNT HOLDER LEGAL SECOND NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERSONAL HEALTH NUMBER (PHN)

BIRTHDATE (MM / DD / YYYY)

 

GENDER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3ADDRESS CHANGE – PLEASE PROVIDE NEW ADDRESS INFORMATION

RESIDENTIAL ADDRESS

DAYTIME TELEPHONE NUMBER

F

CITY

PROV POSTAL CODE

MAILING ADDRESS (IF DIFFERENT FROM RESIDENTIAL ADDRESS)

CITY

PROV POSTAL CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4AUTHORIZATION – MUST BE SIGNED (DO NOT CHANGE TEXT OF AUTHORIZATION BELOW)

I understand the information I have given is collected under the authority of the Medicare Protection Act and may be used to assess eligibility for other Ministry of Health programs, and that practitioners who provide service(s) under MSP are required under the Medicare Protection Act to release information relative to those services to MSP to support claims for benefits.

I declare that all information provided is true and I understand that the Ministry and/or Health Insurance BC may verify this information with immigration authorities, law enforcement authorities and other public authorities, agencies and persons as appropriate. I declare that all persons listed are residents of British Columbia.

SIGNATURE OF ACCOUNT HOLDER

SIGNATURE OF ACCOUNT HOLDER’S SPOUSE

DATE SIGNED (MM / DD / YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5GROUP ADMINISTRATOR – AUTHORIZATION REQUIRED

GROUP NUMBER

AUTHORIZATION NAME OR STAMP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6 CHANGE GROUP PLAN INFORMATION

OLD DEPT / PAYLIST NUMBER

OLD EMPLOYEE / PENSION NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NEW DEPT / PAYLIST NUMBER

NEW EMPLOYEE / PENSION NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Personal information on this form is collected under the authority of the Medicare Protection Act. The information will be used to determine residency in BC and determine eligibility for provincial health care benefits. If you have any questions about the collection of this information, contact Health Insurance BC at the address or telephone numbers below. Personal 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.

Mailing Address: Health Insurance BC, Medical Services Plan, PO Box 9691 Stn Prov Govt, Victoria BC V8W 9P8

Tel: (Lower Mainland) 604 683-7520, (Rest of BC) 1 877 955-5656 Web: www.hibc.gov.bc.ca

HLTH 170 V3 Rev. 2013/09/19

SPOUSE means a resident of BC who is either married to or living and cohabiting in a marriage-like relationship with the applicant and may be of the same gender as the applicant. CHILD means a resident of BC who is the legal ward or child of the applicant, is supported by the applicant, is neither married nor living and cohabiting in a marriage-like relationship, and is either age 18 or younger, or age 19 to 24 and attending school or university full time.

7 SPOUSE

SPOUSE LEGAL LAST NAME

 

 

 

 

 

 

 

 

 

 

 

SPOUSE LEGAL FIRST NAME

 

 

 

 

 

SPOUSE LEGAL SECOND NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERSONAL HEALTH NUMBER (PHN)

 

 

BIRTHDATE (MM / DD/ YYYY)

GENDER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

F

➤

CHANGE/CORRECT SPOUSE’S INFORMATION

 

LEGAL DOCUMENTS ARE REQUIRED FOR MSP TO CONFIRM A CHANGE OR CORRECTION. PROVIDE PHOTOCOPY OF

 

APPLICABLE DOCUMENT; e.g., PROOF OF STATUS IN CANADA (SEE BELOW) OR MARRIAGE/CHANGE OF NAME CERTIFICATE.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CANCELLATION DATE (MM / DD / YYYY) REASON FOR CANCELLATION

 

 

 

 

 

 

 

 

➤

REMOVE SPOUSE FROM PLAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SPOUSE’S CURRENT MAILING ADDRESS

 

 

 

 

 

 

 

 

 

CITY

PROV POSTAL CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

➤

 

ADD SPOUSE TO PLAN

PROVIDE PHOTOCOPIES OF ALL APPLICABLE DOCUMENTS (DO NOT SEND ORIGINALS). IF LEGAL NAME

 

→

 

DOES NOT MATCH, INCLUDE COPY OF MARRIAGE / CHANGE OF NAME CERTIFICATE, ETC.

 

 

REQUESTED EFFECTIVE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE (MM / DD / YYYY)

 

 

 

MARRIAGE DATE (MM / DD / YYYY)

SPOUSE’S PREVIOUS LAST NAME (IF APPLICABLE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HAS SPOUSE LIVED IN BC SINCE BIRTH?

 

 

MM / DD / YYYY

 

 

FROM (PROVINCE OR COUNTRY)

IS THIS A PERMANENT MOVE?

 

 

YES

NO

IF NO, MOST RECENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

MOVE TO BC

→

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS IN CANADA (MARK ONE – X )

CANADIAN CITIZEN – Canadian Birth Certificate, Canadian Citizenship Card or Passport

HOLDER OF PERMANENT RESIDENT STATUS – Record of Landing, Permanent Resident Card (front & back) or Confirmation of Permanent Residence

OTHER – Work or Study Permit, etc.

8 CHILD

IF YOU ARE ADDING, REMOVING OR CHANGING INFORMATION FOR MORE THAN ONE CHILD, PLEASE MARK BOX (

X

), ATTACH ADDITIONAL SHEET AND PROVIDE ALL INFORMATION.

CHILD LEGAL LAST NAME

CHILD LEGAL FIRST NAME

 

CHILD LEGAL SECOND NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERSONAL HEALTH NUMBER (PHN)

BIRTHDATE (MM / DD/ YYYY)

GENDER

M

F

➤

CHANGE/CORRECT CHILD’S INFORMATION

 

LEGAL DOCUMENTS ARE REQUIRED FOR MSP TO CONFIRM A CHANGE OR CORRECTION. PROVIDE PHOTOCOPY OF

 

APPLICABLE DOCUMENT; e.g., PROOF OF STATUS IN CANADA (SEE BELOW) OR CHANGE OF NAME CERTIFICATE.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CANCELLATION DATE (MM / DD / YYYY) REASON FOR CANCELLATION

 

 

 

 

 

 

 

 

➤

REMOVE CHILD FROM PLAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHILD’S CURRENT MAILING ADDRESS

 

 

 

 

 

 

 

 

CITY

PROV POSTAL CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

➤

 

ADD CHILD TO PLAN

PROVIDE PHOTOCOPIES OF ALL APPLICABLE DOCUMENTS (DO NOT SEND ORIGINALS). IF LEGAL NAME

→

 

DOES NOT MATCH, INCLUDE COPY OF CHANGE OF NAME CERTIFICATE, ETC.

 

 

 

 

 

 

 

 

 

 

 

 

 

REQUESTED EFFECTIVE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE (MM / DD / YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

(MM / DD / YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

IF CHILD IS NEWLY ADOPTED,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INDICATE DATE OF ADOPTION →

 

 

 

 

 

 

 

 

ENCLOSE PROOF OF ADOPTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HAS CHILD LIVED IN BC SINCE BIRTH?

 

 

 

MM / DD / YYYY

 

 

FROM (PROVINCE OR COUNTRY)

IS THIS A PERMANENT MOVE?

 

 

YES

NO

IF NO, MOST RECENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

MOVE TO BC

 

→

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS IN CANADA (MARK ONE – X )

CANADIAN CITIZEN – Canadian Birth Certificate, Canadian Citizenship Card or Passport

HOLDER OF PERMANENT RESIDENT STATUS – Record of Landing, Permanent Resident Card (front & back) or Confirmation of Permanent Residence

OTHER – Work or Study Permit, etc.

IF THE ABOVE CHILD IS 19 TO 24 YEARS OF AGE AND ATTENDING SCHOOL ON A FULL-TIME BASIS, PLEASE ALSO COMPLETE THE SECTION BELOW.

SCHOOL NAME AND FULL ADDRESS

 

DATE STUDIES WILL BEGIN

DATE STUDIES WILL BE FINISHED

IF SCHOOL IS OUTSIDE BC, ORIGINAL

 

 

(MM / DD / YYYY)

 

 

(MM / DD / YYYY)

DEPARTURE DATE (MM / DD / YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If studying outside BC, the absence must be temporary and solely for the purpose of attending full-time studies

at an accredited educational facility in a program which leads to a degree or certificate recognized in Canada.

9ADDITIONAL REQUIRED INFORMATION – FAILURE TO PROVIDE THIS INFORMATION MAY AFFECT ELIGIBILITY FOR BENEFITS

HAVE YOU OR ANY FAMILY MEMBER BEEN OUTSIDE BC FOR MORE THAN 30 DAYS IN TOTAL IN THE PAST 12 MONTHS?

YES

NO

IF YES, PROVIDE DETAILS BELOW.

WILL YOU OR ANY FAMILY MEMBER BE OUTSIDE BC FOR MORE THAN 30 DAYS IN TOTAL IN THE NEXT 6 MONTHS?

YES

NO

IF YES, PROVIDE DETAILS BELOW.

DEPARTURE DATE (MM / DD / YYYY)

 

RETURN DATE (MM / DD / YYYY)

FAMILY MEMBER NAME, REASON FOR DEPARTURE AND LOCATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF ANYONE LISTED IS AN ACTIVE MEMBER OF, OR HAS BEEN RELEASED FROM, THE CANADIAN ARMED FORCES, RCMP OR AN INSTITUTION, PROVIDE NAME AND, IF APPLICABLE, DISCHARGE DATE:

NAME

(MM / DD / YYYY)

HLTH 170 PAGE 2

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This form needs some specific information; to guarantee consistency, please be sure to take note of the following tips:

1. When filling in the CHILDS, be certain to include all important blanks within the associated part. This will help to expedite the process, allowing for your information to be processed promptly and accurately.

MSP conclusion process clarified (stage 1)

2. Once your current task is complete, take the next step – fill out all of these fields - RESIDENTIAL ADDRESS, MAILING ADDRESS IF DIFFERENT FROM, CITY, CITY, PROV, POSTAL CODE, PROV, POSTAL CODE, AUTHORIZATION MUST BE SIGNED DO, I understand the information I, I declare that all information, SIGNATURE OF ACCOUNT HOLDER, SIGNATURE OF ACCOUNT HOLDERS SPOUSE, DATE SIGNED MM DD YYYY, and GROUP ADMINISTRATOR with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Filling in segment 2 of MSP

3. This next section is related to SPOUSE, SPOUSE LEGAL LAST NAME, SPOUSE LEGAL FIRST NAME, SPOUSE LEGAL SECOND NAME, PERSONAL HEALTH NUMBER PHN, BIRTHDATE MM DD YYYY, GENDER, CHANGECORRECT SPOUSES INFORMATION, LEGAL DOCUMENTS ARE REQUIRED FOR, CANCELLATION DATE MM DD YYYY, REMOVE SPOUSE FROM PLAN, SPOUSES CURRENT MAILING ADDRESS, CITY, PROV, and POSTAL CODE - fill out each of these empty form fields.

Writing section 3 in MSP

4. It's time to proceed to this next segment! In this case you have these CANCELLATION DATE MM DD YYYY, REMOVE CHILD FROM PLAN, CHILDS CURRENT MAILING ADDRESS, CITY, PROV, POSTAL CODE, ADD CHILD TO PLAN, PROVIDE PHOTOCOPIES OF ALL, STATUS IN CANADA MARK ONE X, REQUESTED EFFECTIVE DATE MM DD, IF CHILD IS NEWLY ADOPTED, INDICATE DATE OF ADOPTION, ENCLOSE PROOF OF ADOPTION, MM DD YYYY, and HAS CHILD LIVED IN BC SINCE BIRTH blank fields to complete.

Writing part 4 in MSP

It's easy to get it wrong when filling out your ADD CHILD TO PLAN, thus ensure that you take a second look before you submit it.

5. The form should be finalized by going through this segment. Below you will find a detailed set of blank fields that need accurate information in order for your form usage to be complete: ADDITIONAL REQUIRED INFORMATION, HAVE YOU OR ANY FAMILY MEMBER BEEN, WILL YOU OR ANY FAMILY MEMBER BE, YES, YES, IF YES PROVIDE DETAILS BELOW, IF YES PROVIDE DETAILS BELOW, DEPARTURE DATE MM DD YYYY, RETURN DATE MM DD YYYY, FAMILY MEMBER NAME REASON FOR, IF ANYONE LISTED IS AN ACTIVE, NAME, MM DD YYYY, and HLTH PAGE.

ADDITIONAL REQUIRED INFORMATION, HAVE YOU OR ANY FAMILY MEMBER BEEN, and IF YES PROVIDE DETAILS BELOW in MSP

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