Msp 107 Form – Fill Out and Use This PDF

Medical Services Plan (MSP)

Complete this Action	Information Only	2Documentation to include with your application

General Information

Complete this form IN FULL. Failure to provide ALL required documents may result in the cancellation of your application. Once Health Insurance BC has processed your application, you will be notified in writing.

PART 1 – Qualification Requirements

Describe your unexpected event of financial hardship and any special circumstances you would like us to consider. Please attach a separate sheet of paper.

PART 2 – Current Monthly Household Income

2Provide a copy of your Record of Employment from your most recent job loss (may be obtained from the Employment Insurance [EI] office or, if submitted by your employer electronically, the Service Canada website).

Provide confirmation of your monthly income fromALL sources (e.g. wages, WorkSafeBC, EI).

2 EI benefits may be confirmed with a printout of “My Current Claim” from the Service Canada website. Income that is directly deposited may be confirmed with a copy of your bank statement (you may conceal confidential information, such as your account number).

2If you are not eligible for EI benefits, provide a copy of the letter or statement from EI that indicates the reason you do not qualify.

2If you left your job due to a health condition and were denied EI benefits (or your medical EI benefits have run out), provide a letter of confirmation from your physician that indicates the anticipated date of your recovery.

Enter your bank balance, RRSP investment balance, non-RRSP investment balance and severance pay. This area MUST be filled in (if any of these balances are 0, be sure to enter 0).

2verification of EI benefits (if eligible for "top up"), a letter from your employer confirming the reduced hours and reason for the change, and copies of your previous and current paystubs to show the change to your income.If you are currently employed but your hours have been significantly reduced, please provide the following:

PART 3 – Current Monthly Household Expenses

2If your income is less than your expenses, please attach a separate sheet that explains how you are meeting your expenses.

PART 4 – Declaration and Consent

Your signature, as the applicant, and the signature of your spouse (if applicable) are required.

IMPORTANT NOTE: You will continue to receive billing notices while you are waiting for your application to be processed.

If you have not received a written response within 60 days, please contact Health Insurance BC.

HLTH 107 Rev. 2019/05/22

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Medical Services Plan (MSP)

APPLICATION FOR TEMPORARY PREMIUM ASSISTANCE

Please Note: Temporary Premium Assistance is not a retroactive program.

Medical Services Plan (MSP) premiums will be eliminated as of January 1, 2020. Applications for Temporary Premium Assistance will be accepted until December 31, 2019.

PROGRAM INFORMATION

Temporary Premium Assistance (TPA) provides a short term waiver of Medical Services Plan (MSP) premiums for qualifying individuals and families. It is designed to assist individuals and families who are not able to pay premiums due to a current unexpected financial hardship for which they could not reasonably have budgeted.

To apply for TPA, you must meet all of the following criteria:

you are a Canadian citizen or a holder of permanent resident status for the past 12 consecutive months,

you have resided in Canada for the past 12 consecutive months,

you are billed directly for your own MSP Premiums,

you (and your spouse) filed the previous year’s Income Tax return(s),

you are experiencing a current unexpected financial hardship for which you could not reasonably have budgeted, and

the essential living cost for the household exceeds the total income of you and your spouse. Essential living cost does not include consumer debt or loan payments.

MSP enrolment must be complete for you (and your spouse, if applicable). 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 icbc.com.

You may qualify for the Regular Premium Assistance program. This program offers subsidies if you have had a period of low income for the preceding tax year. For more information about Regular Premium Assistance, visit

www.gov.bc.ca/premiumassistance.

Fair PharmaCare helps BC residents with eligible costs of prescriptions and certain medical supplies. Already covered by Fair PharmaCare? Have you experienced a decrease in income? You may qualify for increased Fair PharmaCare coverage. For more information or to register, visit www.gov.bc.ca/pharmacare or contact Health Insurance BC.

HEALTH INSURANCE BC IS NOT RESPONSIBLE FOR MISDIRECTED AND/OR UNDELIVERABLE MAIL.

If you have not received a written response within 60 days of submitting your application, please contact Health Insurance BC.

NOTE: ALL INFORMATION MUST BE PROVIDED OR YOUR APPLICATION MAY BE DECLINED.

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MEDICAL SERVICES PLAN (MSP)

APPLICATION FOR TEMPORARY PREMIUM ASSISTANCE

PART 1 – QUALIFICATION REQUIREMENTS

Provide reason for current unexpected financial hardship and explain how you are paying your expenses if you have no income or your expenses are greater than your income. Attach a sheet of paper including any special circumstances you would like us to consider.

Have you/or your spouse been absent from British Columbia in the past 12 months?

Bank Balance	RRSP Investment	Non-RRSP Investment	Severance		Date	YYYY / MM / DD
$	Balance $	Balance $	Pay $		Severance Pay

PART 3 – CURRENT MONTHLY HOUSEHOLD EXPENSES

Receipts may be requested for the following expenses:

Mortgage	$			Food and toiletries			$
Rent / Strata fees / Pad rent	$			Telephone			$
Room and board	$			Cable			$
Property taxes (monthly)	$			Transportation			$
Heating / Hydro / Oil	$			Other expenses, please list:			$
Home insurance (monthly)	$						$
Medical expenses (other than MSP premiums)	$			TOTAL EXPENSES			$
Child support or alimony	$			CALCULATION (For office use only)
Child care / Day care	$		$

PART 4 – DECLARATION AND CONSENT (Please read and sign. Without signature(s), this application will be returned.)

I declare that all information on this application is true and I authorize Health Insurance BC to verify this information with public authorities, agencies and persons as appropriate.

I consent to the exchange of information pertaining to this application for the purposes of administering the Medical Services Plan.

I will advise Health Insurance BC if there is a change in the circumstances which entitled me to receive Temporary Premium Assistance.

I understand that my claim for Temporary Premium Assistance is subject to audit. If it is subsequently determined I am not entitled to assistance, I agree

that the waived amount will become due and payable.
I am a resident of British Columbia as defined by the Medicare Protection Act.
I am not the child of another beneficiary as defined by the	Medicare Protection Act.
SIGNATURE OF APPLICANT		DAYTIME TELEPHONE NUMBER		CELL PHONE NUMBER		DATE SIGNED
X						YYYY / MM / DD
		(	)	(	)
SIGNATURE OF SPOUSE				SPOUSE'S PERSONAL HEALTH NUMBER (if applicable)
X

HLTH 107 Rev. 2019/05/22	Page 3