Medical Services Plan (MSP) Forms for Medical and Health Care Practitioners


For faster, easier submission, the Pay Practitioner Claim and Pay Patient Claim forms can now be submitted online and are listed in the Online Submission Forms section. All forms are also available in PDF format to be filled out, printed and mailed to Health Insurance BC. Those that cannot be submitted online are in the Fill, Print and Mail Forms section.

Each form has a specific audience, which can include Medical and Health Care Practitioners and/or others. For security and operational reasons, we are unable to accept your comments or questions via the Internet at this time.

NOTE: For information on ordering Travel Assistance Program (TAP) forms, please see Travel Assistance Program – Physicians.


Online Submission Forms:

Listed in alphabetical order

HLTH# Form Title
1916 Pay Patient Claim
(for Medical and Health Care Practitioners)
To submit medical and health care service claims. If a practitioner is opted out, payment may go to the practitioner (power of attorney) or the patient.
1915 Pay Practitioner Claim
(for Medical and Health Care Practitioners)
To submit medical and health care service claims.

Fill, Print and Mail Forms:

Listed in alphabetical order

HLTH# Form Title
2832 Application for Direct Bank Payment (PDF 109K)
(for Medical and Health Care Practitioners) To request MSP to electronically transfer semi-monthly payments into your bank account.
More information
2810 Application for Insured Out of Country Medical Services (PDF 96K )
(for Medical Practitioners)
To recommend out of country medical care for a patient. Completion of this form is not a guarantee of approval for funding.
More information
2994 Application for MSP Billing Number (Dental) (PDF 147K)
To get a MSP billing number if you are new dentist registered with the College of Dental Surgeons.
More information
2996 Application for MSP Billing Number (Midwives) (PDF 126K)
To get a MSP billing number if you are a new registered midwife.
More information
2997 Application for MSP Billing Number (Nurse Practitioners) (PDF 133K)
To get a MSP billing number if you are a new Nurse Practitioner.
More information
2991 Application for MSP Billing Number (Physicians) (PDF 140K)
For new physicians registered with the BC College of Physicians and Surgeons to get a MSP billing number.
More information
2998 Application for MSP Practitioner Number Registered Nurses (Certified) (PDF 125K)
To get a MSP practitioner number if you are a Registered Nurse in a Certified Practice.
More information
2769 Application for Pre-Authorization of Payment Surgery for Alteration of Appearance (PDF 113K)
(for Medical Practitioners)
To request pre-authorization of payment for surgery for alteration of appearance. The surgeon planning the procedure must complete the form.
2820 Application for Teleplan Service-Opted In (PDF 125K)
(for Medical and Health Care Practitioners)
To submit claims electronically to MSP through Teleplan if you are opted into MSP.
More information
2771 Application for Teleplan Service-Opted Out (PDF 125K)
(for Medical and Health Care Practitioners)
To submit claims electronically to MSP through Teleplan if you are opted out of MSP.
More information
1908 Assignment of MSP Payments for Diagnostic Facility Services (PDF 528K)
(for use by Medical Practitioners and Payees)
To assign your MSP payments for diagnostic facility services to a hospital or approved diagnostic facility.
More information
2870 Assignment of Payment (PDF 115K)
(for Medical and Health Care Practitioners)
For designating MSP payments for your services to another practitioner, clinic or hospital.
More information
2875 Assignment of Payment – Alternative Payments Program (APP) (PDF 115K)
(for Medical Practitioners)
To assign reporting of services to an APP service contract payee number. To be used for APP funding arrangements only.
2985 Cancellation of Assignment of MSP Payments for Diagnostic Facility Services (PDF 516K)
(for Medical Practitioners)
To cancel your MSP payments for diagnostic services at an approved diagnostic facility.
2717 Coverage Research (PDF 71K)
(for Medical and Health Care Practitioners)
To submit detailed patient information for coverage research.
2871 Encounter Record Submission Authorization (PDF 111K)
(for Medical Practitioners)
To authorize the submission of electronic encounter records.
4530 Medical Practice Access to PharmaNet Agreement (PDF 605K)
(for Medical Practitioners)
To access PharmaNet from your medical practice(s) for the purpose of providing therapeutic care or treatment to your patients.
More information
3021 No Cardiopulmonary Resuscitation (PDF 643K)
(for Physician and Patient use)
To submit a medical order form to hold both the medical doctor’s order and the capable patient’s consent (noted by their signatures given at the time) for cardiopulmonary resuscitation (CPR) to be withheld from the patient in the event of cardio/pulmonary arrest.
3987 Notification of Expected Death in the Home (PDF 126K)
(for Attending Physician and person authorized to control the disposition)
To notify a Funeral Director regarding an anticipated death in the home.
2839 Orthodontic Program Eligibility Application (PDF 610K)
(for Medical and Health Care Practitioners)
To request funding assistance for a child with a diagnosis of cleft lip and/or palate or syndromic craniofacial anomoly. Completion of this form is not a guarantee of approval for funding.
349 Palliative Care Benefits Program Application (PDF 389K)
(for Medical Practitioners)
To request BC Palliative Care Benefits Program coverage for a patient who has reached the end stage of a life-threatening disease or illness and wishes to receive palliative care at home. For more information, see the BC Palliative Care Benefits Program Physician Guide.
1918 Pay Dentist Claim (PDF 577K)
To submit eligible dental surgery claims.
1916 Pay Patient Claim (PDF 546K) (for Medical and Health Care Practitioners)
To submit medical and health care service claims for opted-out practitioners. After September 30, 2012, this Claim Form will no longer be processed if submitted by mail. However, the following claim types are permitted exemptions and can continue to be submitted by mail:
  • Correctional facilities claims
  • Claims for patients covered under the Critical Care Coverage Program
To submit online, go to the Pay Patient Online Submission Form
More information
1915 Pay Practitioner Claim (PDF 545K)
(for Medical and Health Care Practitioners)
To submit medical and health care service claims. After September 30, 2012, this Claim Form will no longer be processed if submitted by mail. However, the following claim types are permitted exemptions and can continue to be submitted by mail:
  • Correctional facilities claims
  • Claims for patients covered under the Critical Care Coverage Program
To submit online, go to the Pay Practitioner Claim Online Submission Form
More information
1917 Pay Reciprocal Practitioner Claim (PDF 536K)
To submit for services provided to residents of provinces or territories other than British Columbia or Quebec.
Physician Claim Form for Out of Province Patient (PDF 610K ) (goes to outside website)
(for Medical and Health Care Practitioners)
For BC physicians submitting medical claims to an out of province health care plan (Quebec)
2848 Practitioner Registration Form (PDF 126K)
(for Health Care Practitioners)
To enrol with MSP if you are licensed to practice in BC as a Supplementary Benefit Practitioner, including: Naturopaths, Massage Therapists, Chiropractors, Optometrists, Physical Therapists, Podiatrists and Acupuncturists. More information about enrolment is available at http://www.health.gov.bc.ca/msp/infoprac/enroll.html.
More information
2943 Practitioner Request for Approval of Over-age Claims (PDF 533K )
To request over-age claims (over 90 days) which are categorized as Submission Code A.
1936 RN(C) Practitioner Information Profile (PDF 577K)
For Registered Nurses in Certified Practice to register with Laboratory Service Providers.


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