MSP Assignment

  • ASSIGNMENT OF MEDICAL SERVICES PLAN BENEFITS TO OPTED OUT PRACTITIONERS
    Dr. Chen (Vicki) Chen* MSP Practitioner #87571

    I,
    authorize the Medical Services Plan of BC to pay Dr. Chen (Vicki) Chen, directly for all reimbursements for benefits payable to me under the Medical and Health Care Services Regulation for care provided to me by Dr. Chen (Vicki) Chen.
    I make this statement in full knowledge of the amount that i will be personally responsible for and the amount that is reimbursable by the Medical Services Plan which will be directed to Dr. Chen (Vicki) Chen to be applied against outstanding monies I owe for services provided.
  • (your name as it appears on card)
  • Date Format: YYYY slash MM slash DD
  • Dear, Patient

    This form allows Dr. Chen (Vicki) Chen to receive your MSP reimbursement directly for services that are MSP benefits. Your practitioner, by law, must advise you of his/her full fee and what portion will be reimbursed by MSP. By agreement, your practitioner may not charge you the portion reimbursable by MSP.



    Signature of Patient or Guardian


    Date:
  • *Dr. Chen Chen, Optometric Corporation