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Forms for Medical & Health Care Practitioners

Last updated on August 26, 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/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 Practitioner Number as a Nurse Practitioner, Registered Nurse,
or Registered Psychiatric Nurse.

2998

Apply for an MSP Practitioner Number as a Nurse in Certified Practice (Registered Nurse or Registered Psychiatric Nurse).
3002

Apply for an MSP Practitioner Number as a Pharmacist.

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.

Travel Assistance Program (TAP BC) forms can be requested by phone or fax.