myBenefits Card Registration Form

myBenefits Card

Eligible for the Health and Dental plan and want to use your benefits? Your Benefits Card allows you direct billing with pharmacies and dental offices.

The myBenefits Card is an important piece of identification that will ease access to your benefits. All eligible students must complete the myBenefits Card Registration Form. This multi-purpose card provides your policy information for submission of claims at both the Pharmacy and some Dental Offices.

To obtain your myBenefits Card you must first register for BC Fair Pharmacare. Once your registration is completed simply complete the form below. Unless you are an International student or from out of province, please list your home province or country of residence.

Set up your online insurance account to use all Plan Card features, visit submitting claims to learn more about Pay-direct claims and Online and Mobile Claims.

Student Information

Student ID Number

Email Address

Confirm Email Address

First Name

Last Name

Gender

FMU

Date of Birth

Date Month Field Date Day Field Date Year Field

Phone Number

Phone Area Number Phone Local Number Phone Digits

Campus

Program Name

Program Start Date

Date Month Field Date Day Field Date Year Field

British Columbian Students - Please list your BC Fair PharmaCare Number
Out of Province Students - Please list your home province
International Students - Please list your country of residence

BC Fair PharmaCare Registration No.

Please indicate how you would like to access your benefits card

Please send an electronic version of myBenefits Card to the email address provide above

Enrolment in the Student Health and Dental plan is not guaranteed by submitting this form; The Student must be enrolled into an eligible full-time program. Should you have any questions regarding the enrolment process please contact the BCITSA Health & Dental Plan Office prior to submitting this form.

I understand the information provided above is required in order to obtain the said pay direct drug card. I hereby authorize and consent to the use, release, and exchange of the above information between the institution, the student organization, the Student Service Co-ordinator, Gallivan & Associates, BCE Emergis Assure Health Division, and the insurance carrier(s) to be used solely in connection with the Student Benefits Plan. I confirm that all the information provided herein is accurate. I also understand that the Student Service Coordinator may need to notify the institution to find out whether or not I have paid for the plan.

I Agree to the Terms & Conditions

Online forms Deadline
Add Family, Opt-in or Opt-out
Submit your applications before 30 days from the official start date of your program

myBenefits Card Registration
Access direct billing with pharmacies and dental offices. Generate it now!

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