Contract Payee Reservation Request

This form is for contract managers at health authorities and other agencies delivering health services to reserve a Y-status payee for a contracted clinical program. Y-status payees are used to provide encounter reporting to Teleplan or to recover MSP payments to service contract budgets. Requests will be reviewed by staff in the Alternative Payments Program and forwarded to Health Insurance BC to be reserved if it is determined that it is for a net-new contracted program that does not already have payee reserved for it. This form should not be used to request payees for fee-for-service practices and requests of this nature will not be processed.

Service TypeMissing or incorrect valuee.g. Primary Care; Laboratory Medicine; Surgical Services; etc.

Facility NameMissing or incorrect valueIf region-wide, please put “Region-Wide”

Facility AddressMissing or incorrect valueIf region-wide, address of office where service is coordinated.

CityMissing or incorrect value

Province

Postal CodeMissing or incorrect value

Contact NameMissing or incorrect value

Contact EmailMissing or incorrect value

Contact Phone Number Missing or incorrect value

Program AreaMissing or incorrect valueName of the clinical program. If related to an existing program, please provide the same name already as used in SCRUBS

Is this service health authority wide?

Payee Start Date

Missing or incorrect valueShould align with the start of a contract

CPRD ID (if created)

Contract Payee Reservation Request

Keep a Copy for Your Records (optional)

Submit Your Form

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