Government of Ontario

ServiceOntario

Microfilm use only

Health Card Renewal – Child

Audit ID

Last name, first name, middle name and mailing address

Mailing address changes

Residential address

Residential address changes

Child's date of birth (yyyy/mm/dd)  
Child's Birth Registration Number
Citizenship / Immigration Document Number

I confirm that:

• My child's primary place of residence is and will continue to be in Ontario.
  
  
• My child will be physically present in Ontario for at least 153 days in any twelve-month period to retain OHIP coverage.
  
  
• The information I have provided on this form, and in the documents I have provided, is true and accurate.
  
  
• I authorize you to obtain my child's Birth Registration Number from the Ontario Registrar General if I have not provided it above.

I understand that:

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

Parent / Guardian 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 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.

Government of Ontario

ServiceOntario

Health Card Renewal – Child

Read the instructions before completing this form.

• A separate form is needed for each child.
  
  
• Complete the form and indicate any changes to your child's address if he/she has recently moved.
  
  If your child's mailing address is different from his/her 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.

1. If you recently received a Renewal Notice for your child that indicated you could complete your child's health card renewal by mail, please mail the completed form to:
   
   ServiceOntario
   PO Box 48
   Kingston ON  K7L 5J3
   
   
   
2. If you recently received a notice that indicated you must visit an office to renew your child's health card, please take the completed form with you to a ServiceOntario Health Card Services – OHIP location.
   
   
   • Health Card Services – OHIP locations may be found on the ServiceOntario website or by calling the Health Card Information System.
     
     
   • If none of these locations is convenient for you, please call ServiceOntario at
     1 888 376–5197 and inquire about Outreach services for smaller communities.
     For teletypewriter (TTY) service, call 1 800 387–5559.
     
     
   • Also take your 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 Health Card Services – OHIP office. Please note that a document used for List 2 may not be used for List 3; two separate documents are required.
   
   
   
3. If you are unsure whether you may mail your child's health card renewal form or if you need to visit a ServiceOntario location, please call 1 888 376–5197 for information.
   For TTY service, call 1 800 387–5559.
   
   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