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

ServiceOntario

Microfilm use only

Health Card Re-Registration

Health Number

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

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.
It is an offence to knowingly provide false information in, or in relation to, this application.

Name (please print)

Telephone (home)

Work or other telephone no.

Signature of applicant
parent
guardian
power of attorney

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 and/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 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 collection practices, call 1 800 268–1154 or write to the Director, Registration and Claims Branch, PO Box 48, Kingston ON K7L 5J3.

Ministry use only

Health Number

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

Date
P. Clerk number
Initials

Cit.

Name on document
Cit type
Effective date
End date
Document type
Issued by
Document no.
Client ID

Res

Document type
Document source

Document type
Document source
Organ donor

Exemptions

A P S

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

ServiceOntario

Health Card Re-Registraton

Read the instructions before completing this form.

A separate form is needed for each person who is changing from a red and white health card to a photo health card.
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 Health Card Services – OHIP office.
- Health Card Services . OHIP locations may be found on the ServiceOntario website or by calling the Health Card Information System.
- If none of these offices are 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 an original document from each of the 3 lists 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 one list may not be used for another list; three separate documents are required.

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