Instructions

Please be sure to have all supporting documents with you.

A. Personal information

All applicants must complete this section.

If your mailing address is a P.O. Box, Rural Route, or General Delivery, then you must provide your civic address in the residence address section. You will be asked to provide a document that proves your primary place of residence is in Ontario. Please refer to the Ontario Health Insurance Coverage Document List for acceptable documents that can be presented for residency.

B. New or Returning Residents of Ontario

If you are new to Ontario or you are returning from an absence from Ontario, complete this section.

C. Agreement

If you are over the age of 16 you must read and sign this section. Your photograph will be taken and will appear on your Health Card. A parent or legal guardian may sign for applicants under the age of 16 years.

Note: Health Cards for children under 15 ½ years of age:

Children under 15 ½ years of age will not have a photograph taken therefore they do not need to be present to be registered. A parent or legal guardian should bring the child’s original documents and this form to a ServiceOntario / Health Card Services (OHIP) Office.
If you have a child who will be turning 16 within the next 6 months, he/she can obtain a photo Health Card and will need to apply in person.

Government of Ontario

ServiceOntario

Registration for Ontario Health Insurance Coverage

Microfilm use only

If you are new or returning to Ontario, complete sections A, B, and C.
If you are renewing your photo Health Card, complete sections A and C.

Refer to the Ontario Health Insurance Coverage Document List for the list of documents you will need to present with your application.
Please print and use a blue or black pen.

Facility Use Only

Number Reference Number

A. Personal information

Last Name
First Name
Middle Name

Sex

Male Female

Date of Birth (yyyy/mm/dd)

Official language preference?

English French

Have you ever had an Ontario Health Number?

Yes No
If yes, what was the number?

Home Telephone Number

No Telephone

Work or other Telephone Number Extension

Mailing Address

Apartment
Street Number and Name, R.R., P.O. Box or General Delivery
City
Province
Postal Code
Country

Residence address
(if different from above)

Apartment
SStreet Number and Name, or lot, concession and township
City
Province ON
Postal Code
Country CANADA
Date moved to this address (yyyy/mm/dd)

B. Section to be completed only by new or returning residents

Where did you move from?

(Apartment number, street number and name)
City
Province/State
Country

When did you leave the above address? (yyyy/mm/dd)
When did you arrive to Ontario? (yyyy/mm/dd)
When did you take up permanent residence in Ontario? (yyyy/mm/dd)

How long do you plan to live in Ontario?

permanently temporarily

If you moved from another part of Canada, were
you covered by a government health plan?

No Yes
If yes, what was your health number?

Are you a Canadian citizen returning to Canada?

No Yes

Are you an immigrant returning to Canada?

No Yes

Are you a new immigrant?

No Yes

Have you recently left the Canadian Forces?

No Yes (date of discharge) yyyy/mm/dd

Have you recently been released from a Federal penitentiary?

No Yes (date of release) yyyy/mm/dd

Are you the spouse or dependant of a Regular Force member
of the Canadian Forces?

No Yes

Are you a reservist returning from an out-of-country posting?

No Yes (date of return) yyyy/mm/dd

Are you the spouse or dependant of a reservist currently
deployed by the Canadian Forces into active service?

No Yes

C. Agreement

I confirm that:

I make and intend to continue making Ontario my primary place of residence.
I will be physically present in Ontario for at least 5 months (153 days) in any 12-month period.
I must not be absent from Ontario for more than 30 days within the first 183 days immediately after establishing residency in Ontario unless I am considered by the Ministry of Health and Long-Term Care to be one of the following or I could lose my OHIP coverage: a Mobile Worker or a Mobile Student, a person who has moved to Ontario directly from another province or territory of Canada where I was insured under a publicly funded health care insurance plan, a Reservist returning from an out-of-country posting or the spouse and/or dependant of a Regular Force member of the Canadian Forces, or the spouse and/or dependant of a Reservist currently deployed by the Canadian Forces into active service.
The information I have given in this application, and in the documents I have provided, is true and accurate.

I understand that:

If there is a change in my name, address, citizenship or immigration status, I will tell the Ministry of Health and Long-Term Care and/or its agent ServiceOntario within 30 days.
The Ministry of Health and Long-Term Care and/or its agent ServiceOntario may check my residence status and any information I have given in this form and in the documents I have provided.
For verification this information may be collected from, and disclosed to, government and non-government organizations, if the law allows it.
It is an offence to knowingly provide false information in relation to this application.

Signature of

applicant
parent
legal guardian
power of attorney

Signature

Date

Collection of the personal health information on this form is for assessment and verification of eligibility for Ontario health insurance coverage, or related programs, health planning and research, and the administration of the Health Insurance Act and the Ontario Drug Benefit Act. The information may be used and disclosed in accordance with the Personal Health Information Protection Act, 2004, and as set out by the “Ministry of Health and Long-Term Care Statement of Information Practices” which may be accessed at www.health.gov.on.ca. I understand that I may withhold my consent to the collection of this information; but that in doing so may interfere with the provision of my Ontario health insurance coverage. For more information, please call ServiceOntario INFOline at 1-800-268-1154.

Ministry use only

Health Number Version code

Date
P. Clerk Number
Initials

Citizenship

Name on document
Cit type
Effective date
End date
Document type
Issued by
Document Number
Client ID

Res.

Document type
Document source

HL
Id.

Document type
Document source
Organ donor

HL
Organ

Exemptions
A P S