Type of Announcement:

Name of Physician or Practice: MSP Billing Number (Optional):

Address:

Phone:

Extension (optional):

Fax:

Email:

Additional information: Announcement to be distributed to the following Districts:

Check all that apply Districts District 1 – Victoria – Lower Island – Brentwood Bay, Esquimalt, , , , Saanich, Saltspring Island, , Sidney, Sooke

District 2 – Nanaimo - Upper Island – Campbell River, Chemainus, Couretnay, Comox, Cowichan Lake, Denman Island, , Duncan, Ladysmith, Mill Bay, Port Hardy, Parksville, Port Alberni, Port McNeill, Qualicum Beach, Shawnigan Lake,

District 3 – Vancouver & Richmond

District 4 – North & West Vancouver , Sunshine Coast, , Bella Coola Valley, Central Coast & Powell River – Bella Bella, , Denny Island, Klemtu, Lund, Pemberton, Powell River, Sechelt, Squamish, Whistler

District 5 – North of Fraser River – Agassiz, Burnaby, Coquitlam, Harrison, Maple Ridge, Mission, New Westminster, Port Coquitlam, Port Moody

District 6 – South of Fraser River – Abbotsford, Chilliwack, Cultus Lake, Delta, Hope, Langley, Surrey

District 7 – Okanagan Thompson – 100 Mile House, Armstrong, Cache Creek, Kamloops, Kelowna, Lillooet, Merritt, Osoyoos, Penticton, Princeton, Revelstoke, Shuswap, Vernon, Williams Lake

District 8 – East/West Kootenays – Castlegar, Cranbrook, Creston, Grand Forks and surrounding areas, Invermere, Kimberley and surrounding areas, Nelson, Trail

District 9 – Skeena – Kitimat and surrounding areas, Prince Rupert, Queen Charlotte Islands, Terrace

District 10 – Cariboo/Peace River – Chetwynd, Dawson Creek, Fort Nelson, Fort St. John, Prince George, Quesnel, Vanderhooff and surrounding areas, Tumbler Ridge Announcement to be distributed to the following Practice type(s):

Check Practice all that Practice Type Name GP/SP apply Type # 0 General Practice GP 22 Surgeon > 50% GP Income GP 27 Pediatrics > 50% GP Income GP 28 Emergency Medicine & GPs > 50% Emerg GP 52 Internists > 50% GP Income GP 53 GPs > 35% Anaesthesia GP 55 GP (Miscellaneous) GP 58 Methadone Program @ 10% + GP 60 GP with Obstetrics & Gynaecology GP 61 General Practice Subset GP 62 GP – Surgical Assist at 35% + GP 63 GP – Primary Care Demo Project GP 65 GP / Specialist > 50% GP Income GP 88 Unknown GP

1 Dermatology SP 2 Neurology SP 3 Psychiatry SP 4 Neuropsychiatry SP 5 Obstetrics & Gynaecology SP 6 Ophthalmology SP 7 Otolaryngology SP 8 General Surgery SP 9 Neurosurgery SP 10 Orthopaedic Surgery SP 11 Plastic Surgery SP 12 Cardio/Thoracic Surgery SP 13 Urology SP 14 Pediatrics SP 15 Internal Medicine SP 16 Radiology SP 17 Pathology & Bacteriology SP 18 Anaesthesia SP 19 Paediatric Cardiology SP 20 Physical Medicine SP 21 Public Health SP 23 Occupational Medicine SP 24 Geriatric Medicine SP 25 Procedural Cardiologist SP 26 Cardiology SP 29 Medical Microbiology SP 33 Nuclear Medicine SP 34 Osteopathy SP 44 Rheumatology SP 45 Allergy & Immunology SP 47 Vascular Surgery SP 48 Chest Surgery SP Check Practice all that Practice Type Name GP/SP apply Type # 49 Respirology SP 51 Endocrinology & Metabolism SP 56 Gastroenterology SP 59 Nephrology SP 67 Infectious Diseases SP 71 Interventional Radiology SP 74 Haematology & Oncology SP

Return the completed Member Mailing Announcement form by:

1. Save and close the file, attach the saved file to a new email message and complete the TO: field with - [email protected]