myBenefits Card Registration Form

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 the Dental Office.

To obtain your myBenefits Card you must first register for BC Fair Pharmacare. Once your registration is completed simply complete the myBenefits Card Registration Form.

Please note: if you are not a permanent resident of BC you must still fill out the registration form providing your home province or country in place of the Fair Pharmacare registration number.

Downloading the myBenefits Card does not confirm eligibility or benefits coverage. Please contact the KSA Benefit Plan Office to confirm your enrolment in the plan.

Student Information

Student ID Number

Email Address

Confirm Email Address

First Name

Last Name

Gender

MaleFemale

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
I will pick up my Benefits Card on Campus
Please mail myBenefits Card to the address provided below

Enrolment in the Student Health and Dental plan not guaranteed by submitting this form; The Student must be eligible for the program.

Should you have any questions regarding the enrolment process please contact the KSA Student Benefit 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

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Deadline: 30 Days from the official start date of your program

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