ServiceOntario
Notice: 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 may verify your residence status and any information you have given on this form and in the documents you have provided.
Read the instructions before completing this form.
Complete this form to:
For the ServiceOntario – Health Card Services – OHIP Office nearest you please call 1 800 664–8988 In Toronto 416 327–7567 For TTY 1 800 387–5559
Need more information? Visit our websites at: www.health.gov.on.ca www.ServiceOntario.ca
Complete this section with your Health Number and the 1 or 2 letter version code (if there is one) exactly as they appear on your Health Card.
Provide your current mailing and residence address. You do not have to visit a ServiceOntario – Health Card Services – OHIP Office for an address change.
If you are correcting/changing your name, sex, date of birth and/or citizenship/immigration status, you will need to visit a ServiceOntario– Health Card Services – OHIP Office. Please refer to the Ontario Health Insurance Coverage Document List (9998–82) as you will be required to provide original documents to support the change/correction.
Complete this section if you qualify under Regulation 552 of the Health Insurance Act for continuous Ontario health insurance coverage while temporarily absent from Ontario for more than 7 months. In all cases, your primary place of residence must be in Ontario. You may be asked for original documentation to support the absence.
Please indicate whether you are traveling within Canada or outside Canada. Please note these are general descriptions only. Regulation 552 of the Health Insurance Act should be consulted for authoritative and regulatory requirements for temporary exemptions from the physical presence requirements in Ontario.
Within Canada – Students: If you are a full-time student, you may be eligible for OHIP for the duration of your studies. You must provide an original letter from school confirming your full-time registration and the expected duration of your program.
Within Canada – Other: If you are traveling or working within Canada, you may remain absent from Ontario for up to a year and maintain your coverage. With the exception of students, persons who plan on spending more than a year elsewhere in Canada should apply for health insurance coverage in their new province or territory.
Outside Canada – Students: If you are a full-time student, you may be eligible for OHIP for the duration of your studies. You must provide an original letter from school confirming your full-time registration and the expected duration of your program.
Outside Canada – Employment: You may be eligible for OHIP for up to 5 years. You must provide an original letter from your employer confirming your full-time employment and the expected duration of your employment.
Outside Canada – Charitable Worker: You may be eligible for OHIP for up to 5 years. You must provide an original letter from the registered charity confirming that you are serving on a full-time basis during the out-of-country assignment and the expected duration of your service.
Outside Canada-Vacation/Other: You may be eligible for OHIP during a vacation or for any other reason for up to two years. This may be taken as two separate 1-year exemptions or one 2-year exemption.
Provide reason for replacement. To replace your Photo Health Card, contact the ministry at 1 800 664–8988. (In Toronto call 416 327–7567. For TTY service call 1 800 387–5559.) To replace a red and white card, you will need to visit a ServiceOntario – Health Card Services– OHIP Office to re-register for a Photo Health Card. Please refer to the Ontario Health Insurance Coverage Document List (9998–82) for acceptable documents that can be presented.
This section is used to cancel a person’s coverage:
Please ensure you read the agreement before signing and dating the form. A custodial parent or legal guardian must sign for a child under 16 years of age. A person holding a valid power of attorney may sign for the represented individual. Provide a copy of the power of attorney.
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 Ontario Drug Benefit Act. The authority for the collection and use of this information is found in the Personal Health Information Protection Act, S.O. 2004, s. 36, the Health Insurance Act, R.S.O. 1990, c.H.6., s.2(3) and 4.1(1) and (2) and the Ontario Drug Benefit Act, R.S.O. 1990, C.O. 10, s.13 (1) and (2). The information may be used and disclosed in accordance with the Personal Health Information Protection Act 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 consent to the collection of this information; however this may interfere with the provision of my Ontario health insurance coverage. For information about the collection practices, call 1 800 268–1154 or write to the Director, Registration and Claims Branch, 4th floor, 49 Place d’Armes, Kingston ON K7L 5J3.
Microfilm use only
Health Number Health Number Version
M F
Date of birth (yyyy/mm/dd) Last name First name Middle name
no telephone
Apartment Street number and name, or P.O. box number, R.R., General Delivery City Province Country Postal Code Effective date of change (yyyy/mm/dd)
Apartment Street number and name, or lot, concession, and township City Province ON Country CANADA Postal Code Effective date of change (yyyy/mm/dd)
Last name First name Middle name
Date of birth (yyyy/mm/dd)
Effective date of change (yyyy/mm/dd)
Canadian First Nations Permanent resident Convention refugee/protected persons Other (specify) :
Departure date (yyyy/mm/dd) Expected date of return (yyyy/mm/dd)
full-time academic studies other (specify)
full-time academic studies employment vacation charitable work other (specify) :
Apt. Street number and name, or P.O. box number, R.R., General Delivery City Province Country Postal Code
Apt. Street number and name, or P.O. box number, R.R., General Delivery City Province ON Country CANADA Postal Code
lost stolen damaged I did not receive my Health Card
death joining Canadian Forces / RCMP leaving Ontario permanently leaving Canada permanently other (specify) : Effective date (yyyy/mm/dd)
Name of person reporting cancellation Relationship Signature
I confirm that:
I understand that:
applicant custodial parent legal guardian power of attorney
Signature Date
Health Number Health Number Version code Date Processing Clerk no. Initials
Name on document Cit type Effective date End date Document type Issued by Document no. Client I.D.
Document type Document source
Document type Document source Organ donor
A P S