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MSP Forms & Documents

  • HLTH 2832 – MSP Payroll Direct Deposit Form
  • HLTH 2848 – Application for MSP Billing Number (Supplementary Opted-Out)
  • HLTH 2848 – MSP Practitioner Registration
  • HLTH 2870 – Assignment of Payment
  • HLTH 2870 – MSP Assignment of Payment to Practitioner
  • HLTH 2943 – Request to Submit Over-Age Claims
  • HLTH 2948 – Application for MSP Facility Number (BCP)
  • HLTH 2976 – Application for Additional MSP Payment Number
  • HLTH 2991 – Application for MSP Billing Number (Physicians & Opted In)
  • MSP Agreement Form for Opted-Out Practitioners

MediClaim Opted-In

  • H2820 – MediClaim MSP Application for Teleplan Service Opted In

MediClaim Opted-Out

  • H2771 – MediClaim MSP Application for Teleplan Service Opted Out

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  • About Us
  • Product
    • MediClaim For Physicians
    • MediClaim For Non-Physician (Supplementary) Practitioners
    • MOAs and Clinics
    • Billing Agents
  • Practitioner Resources
    • MSP Codes & Schedules
    • MSP Forms & Documents
    • MSP Billing Tutorials
    • MSP Monthly Broadcast
  • Contact Us