Government of Ontario: ServiceOntario

Change of Address

Complete for everyone moving to the same address. Each person must sign as declaration that the information is true and accurate. (Parent/guardian may sign for children under 16).

Failure to notify ServiceOntario may affect your health coverage.

Date of Move (year/month/day)

1. New Mailing Address

Apt.
Street no. & name, R.R., P.O. Box, General delivery

City
Province
Country
Postal Code

Is your mailing address a rural route, P.O. Box or General Delivery? If it is, give your residence address below.

Lot, Concession, Township or Street no. & name

City
Province
Country
Postal Code

2. Telephone

Telephone (home)

Telephone (business) ext.

3. Who is moving?

Last Name
First Name

Health Number

Enter the first four digits - Enter the next three digits - Enter the next three digits Version

Date of Birth (year/month/day)
Signature

Person 2

Last Name
First Name

Health Number

Enter the first four digits - Enter the next three digits - Enter the next three digits Version

Date of Birth (year/month/day)
Signature

Person 3

Last Name
First Name

Health Number

Enter the first four digits - Enter the next three digits - Enter the next three digits Version

Date of Birth (year/month/day)
Signature

Person 4

Last Name
First Name

Health Number

Enter the first four digits - Enter the next three digits - Enter the next three digits Version

Date of Birth (year/month/day)
Signature

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 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.