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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