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

ServiceOntario

Microfilm use only

 

Health Card Re-Registration

Health Number

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I confirm that:

I understand that:

Telephone (home)    
Work or other telephone no.    
Signature of





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

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Cit.








Res


Id



Exemptions

     

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

ServiceOntario

Health Card Re-Registraton

Read the instructions before completing this form.