BCITSA Student Health Plan Benefits Card Registration Form The Benefits Card is an important piece of identification that will ease access to your benefits. The multi-purpose card provides your policy information for submission of claims at both the Pharmacy (prescription medications) and the Dental Office (electronic claims).
To get your Fair Pharmacare Registration number, visit http://pharmacare.moh.hnet.bc.ca/ and have ready your: • BC CareCard Number • Net income from 2 years ago • Social Insurance Number • Birth date
About BC Fair Pharmacare The BC Fair Pharmacare program was implemented in May 2003 by the BC government to provide greater financial assistance to BC residents for eligible prescription medications and designated medical supplies. To be eligible, you must be a BC resident and have both a MSP number and a SIN number.
If you experience difficulty registering, or it states that you are already registered, or you prefer to register over the phone please call 604-683-7151 or 1-800-663-7100 for assistance.
Students with a net income of less than $15,000 and on their own MSP will enjoy lower out-of-pocket charges for eligible prescriptions and supplies by enrolling for Fair Pharmacare.
Please note: if you are not a permanent resident of BC you must still fill out the registration form, providing your home province or country in place of the Fair Pharmacare registration number.
It is essential that all students who are permanent residents of British Columbia provide their Fair Pharmacare registration number when completing the Benefits Card Registration form.
To get your Benefits Card once this form is complete: • Bring it to the BCITSA Student Health Plan office, or • Fax it to 604-434-5726, or • Email the registration number, your student ID number, and your mailing address to: healthplan@bcitsa.ca
**If you have previously opted out, you must inform the Benefits Office before submitting this form**
**You are eligible for coverage if you are in a full-time program which is 16 weeks or longer**
STUDENT INFORMATION __________________________________________ Last Name
_________________________________________ First Name
________ Gender
____________/_______/_______ Date of Birth
_________________________________________________________________________ ________________________ ____________________________ Permanent Home Address City/Province Postal Code ___________________________________________ Student ID Number
________________________________________ Campus of Study
AUTHORIZATION
_________________________________________ BC Fair Pharmacare Registration No. **this is NOT your CareCard Number**
I understand the information provided is required in order to obtain the said pay direct drug card. I hereby authorize and consent to the use, release, and exchange of the above information between the institution, the Student Association, the Student Service Coordinator, Gallivan & Associates, BCE Emergis Assure Health Division, and the insurance carrier(s) to be used solely in connection with the Student Benefits Plan. I confirm that all the information provided herein is accurate. I also understand that the Student Service Coordinator may need to communicate with the institution to find out whether or not I have paid for the plan. ______________________________________________________________ Student Signature
(________)_______________________ Phone
________/_______/_________ Date
OFFICE USE ONLY ___________________________________ Member ID
www.bcitsa.ca
___________/_______/________ Processing Date
_________________________________________________________ Processed By