Patient Authorization
I, the patient named above, authorize MSP to pay the practitioner named below directly for reimbursements for benefits payable to me under the Medical and Health Care Services Regulation for care provided to me. I authorize the practitioner to collect MSP payment from the date when this form is signed to the end of the calendar year in which this form is signed.
For each service provided, the practitioner will notify me of the full fee and what portion of the fee they will claim directly from MSP.
- If I qualify for supplementary benefits, I am aware that MSP contributes $23 per visit for a combined annual limit of 10 visits each calendar year for the following services: acupuncture, chiropractic, massage therapy, naturopathy, physical therapy and non-surgical podiatry.
- For other services (e.g. dentistry, optometry, surgical podiatry, and midwifery) MSP contributes an amount in accordance with the relevant payment schedule.
I make this authorization in full knowledge that the practitioner will receive the full amount that is reimbursable to me from MSP for this service, and that I will not receive further reimbursement from MSP for any monies I have paid for this service (if applicable).