Ready to enroll with MSP and MSP Teleplan? Find all MSP forms here.

Application for MSP Payment Number

Fist MSP payment number is required to enroll with MSP and become eligible to bill MSP. Additional payment numbers are required to enable multiple clinics to bill MSP on your behalf without transferring them your payments.

Blank Practitioner Registration Form
HLTH 2848 – Practitioner Registration
Who can use
  • Chiropractors
  • Physical Therapists
  • Acupuncturists
  • Optometrists
  • Massage therapists
  • Podiatrists
  • Naturopaths
When to use
Use this form if you
  • want to enroll with MSP and
  • don’t have a practitioner number yet.
Important
Your choice of Opt In or Opt Out in the  “Billing Option” box determines if you can opt out of MSP Payment Schedule and charge MSP Premium Assistance patients over the limit set up in the schedule. Opt out supplementary healthcare practitioners in B.C., such as chiropractors, physiotherapists, acupuncturists and massage therapists, can charge over $23 per a visit. Opt out optometrists can charge over $46.38 (as of February 1, 2016) for full optometric diagnostic examination of the eyes.
How to submit
  • Download the form to your computer
  • fill it in
  • print
  • sign
  • scan or take a good quality picture and email it to provider.program@hibc.gov.bc.ca or fax it to the number on the form’s bottom.
Outcome
Your will receive a five digit practitioner number, like 12345, in the mail. You will receive it sooner if you phone MSP Teleplan in couple of business days to follow up. Note: Another name for first MSP payment number is MSP practitioner number or MSP billing number.
Questions
Contact MSP Teleplan Support.
Blank MSP Registration Form for Physicians
HLTH 2991 Application for MSP billing number for physicians
Who can use
Physicians
When to use
Use this form if you
  • want to enroll with MSP and
  • don’t have a practitioner number yet.
 How to submit
  • Download the form to your computer
  • fill it in
  • print
  • sign
  • scan or take a good quality picture and email it to provider.program@hibc.gov.bc.ca or fax it to the number on the form’s bottom
Outcome
Your will receive a five digit practitioner number, like 12345, in the mail. You will receive it sooner if you phone MSP Teleplan in couple of business days to follow up. Note: Another name for first MSP payment number is MSP practitioner number or MSP billing number.
Questions
Contact MSP Teleplan Support.
Blank MSP Registration Form for Midwives
HLTH 2996 Application for MSP billing number for midwives
Who can use
Midwives
When to use
Use this form if you
  • want to enroll with MSP and
  • don’t have a billing number yet.
 How to submit
  • Download the form to your computer
  • fill it in
  • print
  • sign
  • scan or take a good quality picture and email it to provider.program@hibc.gov.bc.ca or fax it to the number on the form’s bottom.
Outcome
Your will receive a five digit practitioner number, like 12345, in the mail. You will receive it sooner if you phone MSP Teleplan in couple of business days to follow up. Note: Another name for first MSP payment number is MSP practitioner number or MSP billing number.
Questions
Contact MSP Teleplan Support.
Blank Application for Additional Payment Number
HLTH 2976 Application for additional payment number
Who can use
Any medical or healthcare practitioner or midwife.
When to use
Use this form if
  • you incorporated and want to receive a payment number for your corporation or
  • you want to bill MSP Teleplan through more than one data centre and remain the MSP payee.
How to submit
  • Download the form to your computer
  • fill it in
  • print
  • sign
  • scan or take a good quality picture and email it to provider.program@hibc.gov.bc.ca or fax it to the number on the form’s bottom.
The outcome
Your will receive a five digit practitioner number, like 12345, in the mail. You will receive it sooner if you phone MSP Teleplan in couple of business days to follow up.
How to use it
You will indicate the additional payment number in the Application for Teleplan Services when applying to join more than one data centre because each data center requires a unique payment number. If you received a payment number for your clinic, you can attach it to your data centre, too, and indicate it as a payee number in your claims, so that the MSP payments go to the clinic.
Questions
Contact MSP Teleplan Support.

Teleplan Regsitration for Opt-In Practitioners

Application for MSP Teleplan Service Application for Direct Bank Deposit

Teleplan Registration for Opt-Out Practitioners

Application for MSP Teleplan Service Application for Direct Bank Deposit   Agreement with MSP

Application for MSP Teleplan

Required to bill MSP Teleplan by your own billing software, such as Claim Manager.

Blank Teleplan Application form

HLTH 2771 Application for Teleplan-Service for Opted Out Practitioners

Sample Teleplan Application forms

A sample application for Teleplan service for a solo practitioner (HLTH 2771)
A sample application for Teleplan service for a practitioner who runs a clinic (HLTH 2771)
A sample application for Teleplan service when joining another DCN (HLTH 2771)

Use this form if you are

Opt out.

This form applies mostly to chiropractors, physiotherapists, acupuncturists, massage therapists, podiatrists, naturopaths  and optometrists.

When to use

Use HLTH 2771 if you want to open your own MSP Teleplan data centre or if you want to join another clinic’s data centre. Do not use if you have made an Assignment of payment to any of the members of the data centre.

Questions

Contact MSP Teleplan Support.

 Note:
  1. Opted-out means a practitioner who is allowed to charge more than stipulated in MSP Payment Schedule.
  2. If transferring to a new Teleplan data centre, put a note anywhere on the form or in the cover letter, “Please transfer on this date”.
  3. If hard opt out, put a note anywhere on the form or in the cover letter, “The Agreement is not needed. Payments go to patients.”
Blank Teleplan application form

HLTH 2820 Application for Teleplan Service for Opted In Practitioners

Sample Teleplan Application forms

A sample application for Teleplan service for a solo practitioner (HLTH 2820)
A sample application for Teleplan service for a practitioner who runs a clinic (HLTH 2820)
A sample application for Teleplan service when joining another clinic’s DCN (HLTH 2820)

Use this form if you are

Opt in.

This form applies mostly to midwives and physicians.

When to use

Use HLTH 2820 if you want to open your own MSP Teleplan Data Centre Number (DCN) or if you want to join another clinic’s DCN. Do not use if you have made an Assignment of payment.

 Questions

Contact MSP Teleplan Support.

Note:

  1. Opted-in means a practitioner who is not allowed to charge more than stipulated in MSP Payment Schedule.
  2. If transferring to a new Teleplan data centre number, put a note anywhere on the form or in the cover letter, “Please transfer on this date”.
Fill in and submit
  • Save the file to your computer
  • fill the data in
  • print
  • sign
  • scan or take a good quality picture and email to provider.program@hibc.gov.bc.ca or fax to the number on the form’s bottom
Note: Predate the form with the first date of service that you want to bill to Teleplan electronically (no more than 90 days ago).
 Processing time
The application is processed sooner if you phone MSP Teleplan in a couple of business days to follow up. Otherwise, you will receive the reply in the mail.
The outcome
If applying for a new DCN, you will receive a unique data centre number, which looks like T1234, and Teleplan login name and password. You have to change your Teleplan password on Teleplan web portal before submitting your claims. If applying to join existing DCN, you will receive no credentials because the data centre already has a number, login name and password.
Questions
Contact MSP Teleplan Support.
After registering for Teleplan
If applied for a new data centre number, open a new account in Claim Manager and enter your data centre number information. Don’t forget to change your Teleplan password. You can bill MSP Teleplan immediately. If applied to join existing data centre number, have the receptionist to add your profile to the data centre account in Claim Manager. You can bill MSP Teleplan immediately.

Direct Bank Payment from MSP

Required to receive MSP payments directly into your bank account.

MSP Direct Dank Payment Form
HLTH 2832 Application for direct bank payment from MSP
Who can apply for MSP direct bank payment
Any opted-in and soft opted-out practitioners can apply for direct bank payment from MSP. Not applicable for hard opt-out practitioners.
When to use
Use this form if you want to
  • receive MSP benefits directly to your bank account.
  • change your banking information with MSP.
How to submit
  • Download the form to your computer
  • Fill it in
  • Print
  • Sign
  • Attach a copy of your void cheque
  • Scan or take a good quality picture and email both documents to provider.program@hibc.gov.bc.ca
  • or fax them to the number on the form’s bottom
Follow up
Contact MSP Teleplan support next business day to confirm that the form was received.
Application outcome
Your next MSP Teleplan payment will be deposited into your bank account.
Questions
Contact MSP Teleplan Support. Note:
  1. The form HLTH 28320 is usually submitted with Application for Teleplan service form.
  2. If you don’t have a bank cheque, submit any printout from your online bank account that shows your payment data.
  3. If you have multiple MSP payment numbers, submit a form for each number.
  4. Without the form, MSP payments are made by cheques.

Agreement between MSP and Opted Out Practitioner

Required to switch the payments of MSP benefits from patients to the practitioner.

Blank MSP Agreement Form
Agreement between MSP and Opt Out Practitioner
Submit this form if you
  • have opted out of MSP payment schedule and
  • want to become soft opt out, which means becoming a payee of MSP benefits.
How to submit the MSP Agreement
  • Download it to your computer
  • Print it out
  • Fill it in
  • Sign
  • Scan or take a good quality picture and email to provider.program@hibc.gov.bc.ca or fax to the number on the form’s bottom.
Questions
Contact MSP Teleplan Support. Notes:
  1. Opt-out practitioners who choose not to submit this form become hard opt-out, which means that MSP pays the benefits directly to the patients. Hard opt-out practitioners are still required to submit MSP claims on their patients behalf.
  2. The form is not applicable to opt-in practitioners.
  3. MSP Agreement is usually submitted along with MSP Teleplan Service Application.
  4. Predate the form with the date of the first service when you treated a patient as soft opt-out.

Assignment of Payment under MSP

Required to enable another clinic to bill MSP Teleplan on your behalf while authorizing the clinic to collect your MSP payments.

Blank form
HLTH 2870 Assignment of payment due to practitioner under the medical services plan
Who can use
Any practitioner can assign his or her MSP payments to another practitioner or a clinic if they have same billing option.
When to use
Use Assignment of Payments if
  • you are working for a clinic
  • you want your MSP billing done through the clinic’s software
  • you agree not to be a payee of MSP benefits for your services in the clinic
Questions
Contact MSP Teleplan Support. Notes:
  1. No need to join the clinic’s data centre number if you have done an Assignment of Payment.
  2. Under the Assignment of payments, the treating practitioner gets paid by the assignee, not MSP Teleplan. These transactions might affect the assigner’s accounting.

MSP Billing Forms

More useful forms for MSP billing.

Approval of Over-Age Claims

Required for submitting claims that are older than 90 days.

Blank form for over-age claims approval
HLTH 2943 Practitioner request for approval of over age claims
Who can use
Any medical or healthcare practitioner, optometrist or midwife.
When to use
Submit this form before billing MSP for claims that occurred more than 90 days ago.
How to fill in
  • The request is submitted not for specific claims, but rather for a time period during which the claims occurred. You are required to provide an approximate number of over-age claims, but the exact number is not required.
  • If getting approval for multiple claims, use the range of dates in the Section 2 “Claim Information.” Enter the dates of the earliest and latest claims there.
  • If getting approval for more than five claims, only enter information on five of them in the Verification part of Section 2. You do not need to enter information on all claims that you want to get approved.
  • If getting approval for less than five claims, some of the five lines in the Verification part of Section 2 will remain empty.
HOW TO SUBMIT
  • Download the form to your computer
  • fill it in
  • print
  • sign
  • fax o the billing support at (250) 405-3593.
The outcome
You will receive an approval or a refusal. The refusal might be appealed. The approval will be in effect for any claims that happened in the approved date range. Claims that fall outside of the approved range will be declined.
Questions
Contact MSP Teleplan Support.

Assignment of Payments from the Patient

Required to be kept in the patients’ files of soft opt-out practitioners.

Sample of The Assignment of MSP Benefit to Soft Opt-Out Practitioner
Assignment of payments from the patient to the practitioner .
Who can use
Soft opt-out medical and healthcare practitioners
When to use
A signed copy of the Assignment of MSP Benefits form must be kept in the file of every MSP Premium Assistance patient. These forms might be a part of an audit conducted by MSP. They are not required for opt-in or hard opt-out practitioners.
Questions
Contact MSP Teleplan Support.

Application for MSP Premium Assistance

A hand-out for patients who might qualify for MSP Premium Assistance.

Blank of the Application for MSP premium assistance
HLTH 119 Application for regular premium assistance
Who can use
Any medical and healthcare practitioners
When to use
Distribute this form among low-income patients who might qualify for MSP Premium Assistance. The MSP Premium Assistance status might be granted after the patient submits this form to MSP. This status provides for lower MSP premiums and for additional MSP benefits, such as partial payment for services provided by chiropractors, acupuncturists, massage therapists, physiotherapists, podiatrists and naturopaths.

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