Form Hlth 170 – Fill Out and Use This PDF

Form Hlth 170 is a social well-being class designed for first year McMaster students. It provides insight into understanding their level of internal and external mental health, thereby setting the foundations for healthy and balanced lifestyle choices. Through formative and reflective activities, the course presents disciplinary concepts from a variety of fields such as psychology, population health approach and even counselling to guide life decisions. Ultimately, form HLTH 170 allows students to recognize factors that influence emotions, create opportunities to understand health from multiple perspectives and approach potential challenges as social agents for change.

Form Hlth 170 PDF Details

In California, all students are required to complete a physical education (PE) course in order to graduate from high school. Schools have the option of offering either one semester or two semesters of PE, and the type of PE offered can vary by district. While some students may be physically active outside of school, others may not have any experience participating in physical activity. In this blog post we provide an overview of Form Hlth 170 – a physical education curriculum that is widely used in California high schools. We discuss the benefits of using Form Hlth 170 and highlight some key components of the curriculum.

Question	Answer
Form Name	Form Hlth 170
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	BIRTHDATE, 9P8, 2012, V8W

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MEDICAL SERVICES PLAN (MSP)

GROUP CHANGE REQUEST

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

3ADDRESS CHANGE – PLEASE PROVIDE NEW ADDRESS INFORMATION

RESIDENTIAL ADDRESS

DAYTIME TELEPHONE NUMBER

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

➤

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

IF NO, MOST RECENT

YES

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 (

), 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

➤

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

IF NO, MOST RECENT

YES

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)

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

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

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

How to Edit Form Hlth 170 Online for Free

CHILDS can be filled in very easily. Just open FormsPal PDF editor to accomplish the job quickly. In order to make our editor better and more convenient to work with, we consistently work on new features, with our users' suggestions in mind. All it requires is just a few easy steps:

Step 1: Click the "Get Form" button above on this page to open our PDF editor.

Step 2: As you launch the tool, you will find the form ready to be filled in. In addition to filling out different blank fields, it's also possible to perform many other things with the PDF, particularly adding any words, changing the original textual content, inserting images, placing your signature to the document, and much more.

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!

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.

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.

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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Form Hlth 170 – Fill Out and Use This PDF

Form Hlth 170 PDF Details

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