Date Change Request Form

* = required field

Personal Information

* First Name:

* Last Name:

Student Number:

* Date of Birth:

(month/day/year)

* Effective date shown
on IMED Card:

Year:

Telephone #:

* Email address:

* Program type:

Date Change Request Details

Important Notes:

1.	Date changes are only given if you arrive in BC in the calendar month after your iMED coverage start date as indicated on your iMED card. For example, for Winter Term 1 students, your iMED card shows that the iMED coverage starts on August 1 but you arrive in September. In this case your coverage dates need to be changed so that you are covered for the entire three-month waiting period for the BC Medical Services Plan (MSP). Your three month waiting period for MSP is determined by the month that you arrive in BC, plus two more months. For example, for Winter Term 1 students, if you arrive in August, your MSP will start in November. But if you arrive in September, your MSP will start in December.

2.	Please submit this form by the end of your third week of classes.

Eligibility Questions:

* 1.	What date did you / will you arrive in BC?	(month/day/year)

	Please attach a copy of the supporting document (e.g., study permit, passport stamp or landing document)
*


	(You are allowed to upload these type of files: jpg, gif, png, bmp, tiff, doc, docx and pdf. We recommend jpg format and maximum file size of 1mb.)

* 2.	Was or will your point of entry into Canada be in a province other than BC?	Yes No

	If ‘Yes’, then what date did you arrive in that province prior to coming to BC?	(month/day/year)

See the “Coverage Dates” page of the “Enrolment” section at the iMED Website (www.david-cummings.com/imed) to view the coverage dates set for your study program and term.

If you have questions, please contact DCIS at 604-228-8816 or by email to imed@david-cummings.com.