Msp 119 Form PDF Details

Are you looking for a way to streamline your business's paperwork process? If so, the MSP 119 form might be just what you need. Developed by the Division of Payment Management (DPM) in partnership with the Department of Health and Human Services (HHS), this standardized electronic payment voucher is designed to simplify and standardize transactions between businesses and federal agencies. In this blog post, we'll explore what an MSP 119 form is, how to complete it correctly, and why companies should consider using it as part of their financial software solution. Let’s dive right in!

QuestionAnswer
Form NameMsp 119 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespremium assistance bc, msp premium assistance application bc, british columbia premium assistance, bc msp premium assistance

Form Preview Example

 

 

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MEDICAL SERVICES PLAN (MSP)

 

 

 

 

 

 

APPLICATION FOR REGULAR

 

 

USE CAPITAL

 

 

PREMIUM ASSISTANCE

 

 

LETTERS ONLY

 

 

AND SUPPLEMENTARY BENEFITS

You can complete and submit this form online at www.gov.bc.ca/MSP/applyforpremiumassistance

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PA

MAILING ADDRESS:

APT / UNIT

 

 

 

 

STREET NUMBER

 

 

 

STREET NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROVINCE

POSTAL CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FINANCIAL INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

You must file your income tax return

TAX YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

0

 

 

 

 

with the Canada Revenue Agency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This information is from my Notice of Assessment or Notice of Reassessment for the tax year

 

 

 

 

 

(CRA) by April 30 each year.

 

 

 

 

 

 

 

 

 

 

 

NET INCOME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Failure to file your income tax return

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

,

 

 

 

 

 

 

 

 

 

 

may impact your eligibility for

Enter your net income (from your Notice of Assessment or Notice of Reassessment)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Regular Premium Assistance and

Note: If net income is a negative number (e.g. – $2,300.00), enter 0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

other income-based programs.

Enter the net income of your spouse

 

 

 

 

 

 

$

 

 

,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Net income is found on line 236 of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Note: If net income is a negative number (e.g. – $2,300.00), enter 0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

the CRA Notice of Assessment or

TOTAL NET INCOME (add lines 1 and 2)

 

 

 

 

 

 

$

 

 

,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notice of Reassessment.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGE

DEDUCTIONS ALLOWED BY THE MEDICAL SERVICES PLAN (MSP)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claim $3,000 for each person who is

SPOUSE - claim $3,000

 

 

 

 

 

 

 

$

 

 

,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

65 or older this year.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

,

 

 

 

 

 

 

 

 

 

 

CHILDREN

If you are 65 or older this year, claim $3,000

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claim $3,000 for each minor (under

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19 years of age) or dependent post-

If your spouse is 65 or older this year, claim $3,000

 

 

 

 

 

 

$

 

 

,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

secondary student (19-24 years of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

age; may include a student enrolled

CHILDREN

 

x $3,000 =

$

 

 

,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

in full-time studies at a trade school,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

number of minors/dependent post-secondary students

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

technical school or high school)

minus one half of the child care expenses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

included under your MSP coverage.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

claimed on your (and/or your spouse’s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DISABILITY

income tax return (1/2 of line 214)

– $

 

 

,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you claimed a disability on your

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

income tax return for yourself, or

Difference (if a negative number, enter 0) =

$

 

 

,

 

 

➮ $

 

,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

your spouse, minor or dependent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

post-secondary student included

Universal Child Care Benefit reported on your

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

under your MSP coverage, claim

(and/or your spouse’s) income tax return (line 117)

 

 

 

 

 

 

$

 

 

,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$3,000 for each disabled person.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you claimed attendant or nursing

DISABILITY

 

x $3,000 =

 

 

 

 

 

 

$

 

 

,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

home expenses in place of disability,

 

number of disabled

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

enclose photocopies of receipts.

Registered Disability Savings Plan income reported on your

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The maximum MSP deduction for

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(and/or your spouse’s) income tax return (line 125)

 

 

 

 

 

 

$

 

 

,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

disability is $3,000 per person.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TOTAL DEDUCTIONS (add lines 4 to 10)

 

 

 

 

 

 

$

 

 

,

 

 

 

 

 

 

 

 

 

 

ADJUSTED NET INCOME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADJUSTED NET INCOME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

is net income from your

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADJUSTED NET INCOME (subtract line 11 from line 3)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notice of Assessment or Notice

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If this amount is $42,000 or less you qualify for Regular Premium Assistance.

 

 

 

,

 

 

 

 

 

 

 

 

 

 

of Reassessment minus above

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

deductions allowed by MSP.

Note: If adjusted net income is a negative number (e.g. – $2,300.00), enter 0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

2

3

4

5

6

7

8

9

10

11

12

.

This form must be signed. Please see reverse/page 2 for the required Declaration and Consent.

WE CANNOT ACCEPT UNSIGNED FORMS.

➤

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 119 V 13 Rev. 2019/05/14

DECLARATION AND CONSENT - MUST BE SIGNED

Mark ( X ) 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 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 Premium Assistance Program and the Supplementary Benefits Program under theMedicare 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 premium assistance and supplementary benefits is requested. It may be revoked by sending a written notice to Health Insurance BC.

I am a resident of British Columbia as defined by the Medicare Protection Act.

I 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.

Mark ( X ) 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 with your application. Failure to update your MSP account if you marry or begin living in a marriage-like relationship may impact eligibility for

Regular Premium Assistance.

APPLICANT SIGNATURE

SPOUSE SIGNATURE

DATE SIGNED (MM / DD / YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICANT FIRST INITIAL AND LAST NAME

APPLICANT SOCIAL INSURANCE NUMBER

SPOUSE FIRST INITIAL AND LAST NAME

SPOUSE SOCIAL INSURANCE NUMBER

SPOUSE PERSONAL HEALTH NUMBER (PHN)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GROUP AUTHORIZATION (if required)

GROUP NUMBER

AUTHORIZATION NAME OR STAMP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAL SERVICES PLAN (MSP) PREMIUM ASSISTANCE INFORMATION

MSP enrolment must be complete for you (and your spouse, if applicable) to qualify for Regular Premium Assistance. 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.

Types of Assistance - Two types of assistance are available:

1.Regular Premium Assistance – offered if your adjusted net income for the previous year is $42,000 or less. To apply for Regular Premium Assistance you must fully complete this form and sign the declaration and consent. If you are married or living in a marriage-like relationship, your spouse must also sign. If you are covered through your employer, pension or union welfare plan, your group administrator will need to complete the Group Authorization section above.

2.Temporary Premium Assistance – offered if you are unable to pay premiums because of a current, unexpected financial hardship. To qualify, you need to provide information that shows you are unable to pay your premiums and could not have reasonably budgeted to do so. For more information, visit: www.gov.bc.ca/temporarypremiumassistance.

Other Benefits- Your application may be used to determine eligibility for other income-based programs: Supplementary Benefits, BC Emergency Health Services, and Healthy Kids. For more information, visit www.gov.bc.ca/premiumassistance.

Fair PharmaCare - Helps BC residents with eligible costs of prescriptions and certain medical supplies. For more information or to register, visit www.gov.bc.ca/pharmacare or contact Health Insurance BC.

Income Verification - The signed declaration above allows the Ministry of Health and/or Health Insurance BC to verify your income information with the Canada Revenue Agency (CRA) on an ongoing basis. In most cases, you do not need to reapply for Regular Premium Assistance as Health Insurance BC will continue to verify your income with CRA each year and will maintain or adjust your level of assistance 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.

Monthly Rates - Once you have completed the application form, look at line 12 to determine your adjusted net income. Find your adjusted net income in the premium rate table to determine your monthly rate. The rates listed below are subject to change.

PREMIUM RATE EFFECTIVE JANUARY 1, 2018

ADJUSTED NET INCOME

One Adult

Two Adults in a Family

 

 

 

$0 - $26,000

$0.00

$0.00

$26,001 - $28,000

$11.50

$23.00

$28,001 - $30,000

$17.50

$35.00

$30,001 - $34,000

$23.00

$46.00

 

 

 

$34,001 - $38,000

$28.00

$56.00

$38,001 - $42,000

$32.50

$65.00

Over $42,000

$37.50

$75.00

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 119 PAGE 2

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This form will require specific details to be typed in, hence be sure you take some time to provide exactly what is required:

1. The hlth 119 necessitates certain information to be inserted. Ensure that the next blank fields are complete:

msp subsidy form completion process explained (portion 1)

2. Once your current task is complete, take the next step – fill out all of these fields - AGE Claim for each person who is, CHILDREN Claim for each minor, DISABILITY If you claimed a, If you claimed attendant or, The maximum MSP deduction for, ADJUSTED NET INCOME is net income, DEDUCTIONS ALLOWED BY THE MEDICAL, SPOUSE claim, If you are or older this year, If your spouse is or older this, CHILDREN, number of minorsdependent, minus one half of the child care, Difference if a negative number, and Universal Child Care Benefit with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

msp subsidy form completion process detailed (stage 2)

As for The maximum MSP deduction for and If you claimed attendant or, be sure that you get them right here. Both of these are surely the most significant ones in this form.

3. Completing DECLARATION AND CONSENT MUST BE, Mark X if someone has Power of, I hereby consent to the release of, I am a resident of British, I have resided in Canada as a, Mark X if you are married or, APPLICANT SIGNATURE, SPOUSE SIGNATURE, DATE SIGNED MM DD YYYY, APPLICANT FIRST INITIAL AND LAST, SPOUSE FIRST INITIAL AND LAST NAME, APPLICANT SOCIAL INSURANCE NUMBER, SPOUSE SOCIAL INSURANCE NUMBER, SPOUSE PERSONAL HEALTH NUMBER PHN, and GROUP AUTHORIZATION if required is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Part no. 3 in filling in msp subsidy form

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