Health Card Medical Exemption Request

Please read these instructions before completing the form.

This form is for use by individuals who, for medical reasons cannot go to a ServiceOntario centre to have their photo or signature captured. It may also be used by individuals who can go to a ServiceOntario centre but, for medical reasons cannot have their photo or signature captured. For example, an individual may not be able to sign their name while they are recovering from an accident or surgery.

Part A - Health Card Holder Information

To be completed by the health card holder or his or her legal representative (must provide appropriate document as proof).

Part B - Declaration of Health Care Provider

To be completed by the health card holder's physician or nurse practitioner.

Bring the completed Health Card Medical Exemption Request form to a ServiceOntario centre. Also bring the following:

A completed health card registration, renewal or re-registration form.
Supporting documents for the cardholder as shown on the Ontario Health Insurance Coverage Document List. One original document from each of the 3 categories is required.
A document supporting a legal representative’s status such as Power of Attorney document.

Need more information?

Visit:

ServiceOntario.ca/HealthCard

www.health.gov.on.ca

Call ServiceOntario at:

Toll-Free: 1-866-532-3161

TTY toll-free: 1-800-387-5559

Health Card Medical Exemption Request

Part A - Health Card Holder Information (to be completed by applicant or legal representative)

Exemption(s) Requested:

Photo Signature Photo and Signature

Health Number
Version
Date of Birth
Last Name
First Name
Middle Name
Street number and Name
City, Town, Village
Postal Code
Home Telephone Number

Declaration

I declare the information I have given in this form and any documents I have provided are true and accurate. I understand that it is an offence to provide false information knowingly.

Signature of Applicant

Date

Part B - Declaration of Health Care Provider (complete both sections)

1. Assessment of Condition

The following is my professional opinion with respect to the exemption(s) requested by the applicant:

The condition(s) is/are expected to be:
Permanent Subject to Change (Requires health reassessment in 5 years)

2. Health Care Provider Information

I am registered with:

College of Physicians & Surgeons of Ontario College of Nurses of Ontario - Registered Nurse (Extended Class)

Signature of Applicant

Date
Health Care Provider's College Number
Telephone Number

Please Print or Stamp Name & Address of Health Care Provider

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 the 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.

Ministry Use Only

Processing Clerk Number
Initials
Date