locum assignment

 

 

 

locum assignment of payment

locum assignment

locum tenens assignment

locum nurse practitioner assignment

locum assignment of payment

locum assignment

locum tenens assignment

locum nurse practitioner assignment

 

hereby assign to , , ,

40 percent of all fee-for-service billings paid by the Medical Services Commission under the Terms and Conditions of the

Locum Agreement bearing my personal practititioner number, , and the Host

Physician’s Payment Number .

The Commission is hereby authorized to pay all such sums directly to

at any address the Host Physician may from time to time designate, with payment of any such sum to be sufficient discharge to the

Commission of and from any indebtedness in that amount to me, my heirs, executors, or administrators.

THIS AGREEMENT is to remain in full force and effect for all claims submitted with the Host Physician’s Payment Number,

, and my Personal Practitioner Number, ,

from to .

I AGREE TO:

• Notify Locums for Rural BC in writing,

immediately upon becoming unavailable to

provide locum services.

• Submit all fee-for-service claims to MSP using the

host physician’s payment number.

I UNDERSTAND:

• Under the 5 Days or Over component, I will receive the greater

of 60% of paid claims or a guaranteed daily rate based on the

community type (A, B, C or D) that I am providing services to

(averaged over the length of the assignment) paid semi-monthly

by direct bank deposit.

• Under the Weekend Coverage component, I will receive the

greater of 60% of paid claims or the weekend rate for 18:00 Friday

to 08:00 Monday coverage paid semi-monthly by direct bank

deposit.

• Adjustments will be calculated and paid 90 days after the end

date of the locum assignment.

• Where applicable, I will receive the on-call MOCAP payments

from the Health Authority/Host physician.

TERMS AND CONDITIONS

Locum Physician Name Locum Physician MSP Practitioner Number

Host Physician / Clinic Name Host Physician / Clinic MSP Payment Number City

Locum Physician MSP Practitioner Number

Host Physician / Clinic MSP Payment Number

Host Physician / Clinic MSP Payment Number

Host Physician / Clinic MSP Payment Number Locum Physician MSP Practitioner Number

Effective Date (MM/DD/YYYY) Cancel Date (MM/DD/YYYY)

I HAVE READ AND UNDERSTAND THE TERMS AND CONDITIONS.

Signature of Locum Physician Date

RURAL GP LOCUM PROGRAM

ASSIGNMENT OF PAYMENT

DUE TO PRACTITIONER

UNDER THE MEDICAL SERVICES PLAN

The information on this form is collected under s.26(c) & (e) of the

Freedom of Information and Protection of Privacy Act and will be used to

place locum physicians as needed and to ensure continuous care for

rural communities. The Ministry of Health is collecting this information

for the purposes of administering and evaluating the program. If you

have any questions about the collection and use of this information,

please contact the Locum Program Officer at 1-877-357-4757, or by mail

at Locums for Rural BC, Renfrew Centre, 300 – 2889 East 12th Avenue,

Vancouver BC V5M 4T5.

Locums for Rural BC administers the Rural Locum Programs

on behalf of the Ministry of Health and Doctors of BC.

Please mail or fax applications to:

Renfrew Centre, 300 – 2889 East 12th Avenue, Vancouver, BC V5M 4T5

Phone: 1 877 357-4757 Fax: 1 877 387-4757

 

The information on this form is collected under s.26(c) & (e)

of the Freedom of Information and Protection of Privacy Act

and will be used to place locum physicians as needed and to

ensure continuous care for rural communities. The Ministry

of Health is collecting this information for the purposes of

administering and evaluating the program. If you have any

questions about the collection and use of this information,

please contact the Locum Program Officer at 1-877-357-4757,

or by mail at Locums for Rural BC, Renfrew Centre, 300 – 2889

East 12th Avenue, Vancouver BC V5M 4T5.

I, , ,

hereby assign to , , ,

40 percent of all fee-for-service billings paid by the Medical Services Commission under the Terms and Conditions of the

Locum Agreement bearing my personal practititioner number, , and the Host

Physician’s Payment Number .

The Commission is hereby authorized to pay all such sums directly to

at any address the host physician may from time to time designate, with payment of any such sum to be sufficient

discharge to the Commission of and from any indebtedness in that amount to me, my heirs, executors, or administrators.

THIS AGREEMENT is to remain in full force and effect for all claims submitted with the Host Physician’s Payment Number,

, and my practitioner number, ,

from to .

Locum Physician’s Full Name Locum Physician’s MSP Practitioner Number

Host Physician’s Full Name Host Physician’s MSP Payment Number City

Locum Physician’s Practitioner Number

Host Physician’s MSP Payment Number

Host Physician’s MSP Payment Number

Host Physician’s MSP Payment Number Locum Physician’s MSP Practitioner Number

Effective Date (MM/DD/YYYY) Cancel Date (MM/DD/YYYY)

Signature of Locum Physician

HOSPITAL-BASED LOCUM SERVICES ONLY – PLEASE COMPLETE IN FULL YOUR MSP PRACTITIONER NO. DO YOU HAVE AN ADDITIONAL YOUR CURRENT RSLP PAYMENT NUMBER

PAYMENT NUMBER FOR RSLP?

LOCUM FULL NAME (FIRST, LAST)

EMAIL ADDRESS WEB/TELEPLAN (IF APPLICABLE): data centre number (when joining

existing site)

ADDRESS

DATES OF LOCUM ASSIGNMENT

FROM (EFFECTIVE DATE - MM/DD/YYYY): TO (CANCEL DATE - MM/DD/YYYY):

NAME OF COMMUNITY WHERE LOCUM IS BEING PROVIDED

I AGREE TO:

• Notify Rural Practice Programs in writing immediately upon becoming

unavailable to provide locum services.

• Submit all fee-for-service claims to MSP using the additional payment

number designated to me.

• Be the responsible physician for this additional payment number and will

only use for the purpose of on call RSLP locum assignments.

I UNDERSTAND:

• I will receive 100 percent of paid claims over and above the $1,500

applicable daily rate (averaged over the length of the assignment).

• Top up adjustments will be calculated and paid 90 days after the end of

the locum assignment.

• I will receive the on-call payments from the health authority / host

physicians.

TERMS AND CONDITIONS (SIGN BELOW)

OFFICE-BASED LOCUM ASSIGNMENT ONLY – PLEASE COMPLETE IN FULL

I AGREE TO:

• Notify Locums for Rural BC in writing immediately upon becoming

unavailable to provide locum services.

• Submit all fee-for-service claims to MSP using the host physician’s

payment number.

I UNDERSTAND:

• I will receive the greater of 60 percent of paid claims or applicable daily rate

(averaged over the length of the assignment) paid semi-monthly.

• Adjustments will be calculated and paid 90 days after the end of the locum

assignment.

• I will receive the on-call payments from the health authority / host physician.

TERMS AND CONDITIONS (SIGN BELOW)

Date

YES NO

RURAL SPECIALIST LOCUM PROGRAM

ASSIGNMENT OF PAYMENT

Locums for Rural BC administers the Rural Locum

Programs on behalf of the Ministry of Health and

Doctors of BC.

Please mail or fax applications to:

Renfrew Centre, 300 – 2889 East 12th Avenue,

Vancouver, BC V5M 4T5

Phone: 1 877 357-4757 Fax: 1 877 387-4757

CITY PROVINCE POSTAL CODE

PHONE NUMBER (INCLUDE AREA CODE)

  

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