I have received information about MSP and agree to abide by the terms and conditions
of MSP. I understand the information I have given is collected under the authority of the Medicare
Protection Act and may be used to assess eligibility for other Ministry of Health Services programs,
and that practitioners who provide service(s) under MSP are required under the Medicare Protection
Act to release information relative to those services to MSP to support claims for benefits.

I declare that all information provided is true and I understand that the Ministry and/or Health Insurance
BC may verify this information with immigration authorities, law enforcement authorities and other public
authorities, agencies and persons as appropriate.

I declare that all persons listed are residents of British Columbia. Resident means a person who is a citizen of Canada or is lawfully admitted to Canada for
permanent residence, who makes his or her home in British Columbia, and is physically present in British Columbia for at least 6 months in a calendar year, or a
shorter prescribed period, and includes a person who is deemed under the regulations to be a resident, but does not include a tourist or visitor to British
Columbia.

I have received information about MSP and agree to abide by the terms and conditions
of MSP. I understand the information I have given is collected under the authority of the Medicare
Protection Act and may be used to assess eligibility for other Ministry of Health programs,
and that practitioners who provide service(s) under MSP are required under the Medicare Protection
Act to release information relative to those services to MSP to support claims for benefits.

I declare that all information provided is true and I understand that the Ministry and/or Health Insurance
BC may verify this information with immigration authorities, law enforcement authorities and other public
authorities, agencies and persons as appropriate.

I declare that all persons listed are residents of British Columbia. Resident means a person who is a citizen of Canada or is lawfully admitted to Canada for
permanent residence, who makes his or her home in British Columbia, and is physically present in British Columbia for at least 6 months in a calendar year, or a
shorter prescribed period, and includes a person who is deemed under the regulations to be a resident, but does not include a tourist or visitor to British
Columbia.

Remove "Services" re: MoH request
Remove "Services" re: MoH request