Government of Ontario: Ministry of Health and Long-Term Care

ServiceOntario

Health Card Renewal

Read the instructions before completing this form.

• A separate form is needed for each person.
  
  
• Complete and sign the form.
  
  
  • If your mailing address is different from your residential (physical) address, please complete both the mailing and residential address sections of the form.
    
    e.g.
    Mailing Address:
    RR1, London ON  N0N 1N0
    
    Residential Address:
    195 Anywhere St., London ON  N0P 1P2
    
    
    
• Don't forget to sign the form.
  
  
• Take the completed form with you to a ServiceOntario centre
  
  
  • ServiceOntario centre may be found at ServiceOntario.ca/findservices
    
    
• Also take an original document from List 2 and List 3 on the Ontario Health Coverage Document List.
  
  If you do not have an original document from each list, obtain them before you visit a ServiceOntario centre. Please note that a document used for List 2 may not be used for List 3; two separate documents are required.
  
  
  • If your citizenship or immigration status has changed since you obtained your current photo health card, also take your new original document from List 1
  
  For additional information visit
  www.ServiceOntario.ca or
  www.health.gov.on.ca
  OR
  Call the Health Card Information System at
  1 800 664–8988
  For teletypewriter (TTY) service,
  call 1 800 387–5559.

Government of Ontario: Ministry of Health and Long-Term Care

ServiceOntario

Microfilm use only

Health Card Renewal

Audit ID

Last name, first name, middle name and mailing address

Mailing address changes

Residential address

Residential address changes

Date of birth (yyyy/mm/dd)  
Official language preference
Sex

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 153 days in any twelve-month period to retain my OHIP coverage.
  
  
• The information I have provided on this form, and in the documents I have provided, is true and accurate.
  
  

I understand that:

• If there is any change in my name, address, citizenship or immigration status, I will inform the Ministry of Health and Long-Term Care or its agent, ServiceOntario, within 30 days.
  
  
• IIt is an offence to knowingly provide false information in, or in relation to, this application.

Name (please print)

Date

This information may be verified using information from government and non-government organizations as permitted by law. The Ministry of Health and Long-Term Care or its agent, ServiceOntario may verify your residence status and any information you have given on this form and in the documents you have provided.

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.