Forms for Medical & Health Care Practitioners
Last updated on January 1, 2024
There are a number of forms which Medical and Health Care Providers may require when they are registering with or claiming services through MSP. For your convenience details and links to these forms are listed below. Forms are also available from Service BC Centres located throughout the province, or by contacting MSP.
- Enrolment Forms
- Assignment of Payment Forms
- Claim Forms
- Teleplan Forms
- MSP Facility Forms
- Business Cost Premium Forms
- Program Application Forms
- Authorization Forms
- Rural Programs Forms (goes to another webpage)
- Miscellaneous Forms
Enrolment/Withdrawal Forms
These forms can be used to apply for enrolment as a practitioner with MSP or to withdraw from enrolment in the Longitudinal Family Physician (LFP) payment model.
| Form # | Form Name and Information |
|---|---|
|
2991 |
Apply for an MSP Billing Number as a licensed physician. |
|
2994 |
Apply for an MSP Billing Number as a licensed dentist. |
|
2848 |
Apply for an MSP Billing Number as a licensed supplementary benefits practitioner. |
|
2996 |
Apply for an MSP Billing Number as a licensed midwife. |
|
2997 |
Apply for an MSP Billing Number as a licensed nurse practitioner, registered nurse or licensed practical nurse. |
|
2998 |
Apply for an MSP Billing Number as a licensed registered nurse (certified). |
|
1936 |
Register with Laboratory Service Providers. |
|
2832 |
Request MSP to electronically transfer semi-monthly payments into your bank account. |
| 2981 |
Submit a request to withdraw from the Longitudinal Family Physician (LFP) payment model. |
Assignment of Payment Forms
These forms can be used to designate MSP payments for your services to another practitioner, clinic or hospital.
| Form # | Form Name and Information |
|---|---|
|
2870 |
Designate MSP payments for your services to another practitioner, clinic or hospital. |
|
2875 |
Assign reporting of services to an APP service contract payee number. |
|
1908 |
Designate MSP payments for your diagnostic facility services to another hospital or diagnostic facility. |
|
2871 |
Authorize the submission of electronic encounter records for licensed nurse practitioners, registered nurses and licensed practical nurses. |
Claim Forms
These forms can be used to submit medical and health care service claims for payment from MSP.
| Form # | Form Name and Information |
|---|---|
|
1915 |
Submit medical and health care service claims for opted-in practitioners. |
|
1916 |
Submit medical and health care service claims for opted-out practitioners. |
|
1918 |
Submit dental care service claims for services for opted-in dentists |
|
1917 |
Submit medical and health care service claims for services provided to residents of provinces or territories other than British Columbia or Quebec. |
|
1980 |
Submit Claims under the Enhanced Urgent Care Coverage Program (EUCCP) |
|
Submit medical and health care service claims for services provided to residents of Quebec. |
|
|
2943 |
Request over-age claims (over 90 days) which are categorized as Submission Code A. |
Teleplan Forms
These forms can be used to apply for registration with Teleplan.
| Form # | Form Name and Information |
|---|---|
|
2771 |
Submit claims electronically to MSP through Teleplan if you are opted out of MSP. |
|
2820 |
Submit claims electronically to MSP through Teleplan if you are opted in to MSP. |
MSP Facility Forms
These forms can be used to apply for an MSP facility number for the Longitudinal Family Physician (LFP) payment model and/or the Business Cost Premium (BCP); or to cancel/change details for a facility with an MSP facility number.
Before completing the Application for MSP Facility Number (New):
- Ensure that no one else has submitted an application for a Facility Number for your facility
- Review the requirements for the Business Cost Premium (BCP) to determine if your facility is eligible if you are requesting that the BCP be applied to your facility (see Business Cost Premium)
| Form # | Form Name and Information |
|---|---|
|
2948 |
Apply for an MSP facility number. |
|
2949 |
Apply to cancel or change details for facilities with an MSP facility number. |
Business Cost Premium Forms
| Form # | Form Name and Information |
|---|---|
|
2948 |
Apply for an MSP facility number. |
|
2949 |
Apply to cancel or change details for facilities with an MSP facility number. |
| 2950 |
Apply to attach a Physician to a MSP Facility Number for Business Cost Premium. |
PharmaCare / PharmaNet Forms
| Form # | Form Name and Information |
|---|---|
|
349 |
Request B.C. 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. |
| 5466 | |
| 3497 | |
| 4530 |
Access PharmaNet from your medical practice for the purpose of providing therapeutic care or treatment to your patients. |
| 4532 |
Authorization Forms
These forms can be used to request or receive authorization from MSP.
| Form # | Form Name and Information |
|---|---|
|
2769 |
Request pre-authorization of payment for surgery for alteration of appearance. |
|
2810 |
Recommend out of country medical care for a patient. |
| 2947 |
Authorizes opted-out practitioners to receive a patient’s MSP reimbursement directly for services that are MSP benefits. |
Miscellaneous Forms
| Form # | Form Name and Information |
|---|---|
| 2839 |
Request funding assistance for a child with a diagnosis of cleft lip and/or palate or syndromic craniofacial anomoly. |
|
2717 |
Submit detailed patient information for coverage research. |
|
302 |
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 |
Notify a funeral director regarding an anticipated death in the home. |