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

Ministry Use Only

Health Number
Ministry Use Only

1 Patient

A. General Information

Last name
First name
Middle name

Birth date(year/month/day)

If an alternate last name is known, please provide

B. Health Number Disclosure

The Ministry of Health and Long-Term Care will give your Health Number to the health care provider/facility.

I agree to allow the Ministry of Health and Long-Term Care to release my Health Number to the health care provider/facility listed below.

_________________________________________
Signature du patient ou du tuteur

Date

Home phone number (xxx-xxx-xxxx)

Business phone number (xxx-xxx-xxxx)

A parent or guardian may sign for a child under 16 years of age. A person holding power of attorney may sign for the represented individual.

2 Provider/Facility

Date of service (year/month/day)

Provider no.

Provider's phone number (xxx-xxx-xxxx)

Facility no.
Facility phone number (xxx-xxx-xxxx)

The Health Number of the patient will be returned to the provider/facility listed here.

Provider name and address

Facility name and address

Collection of the information on this form is for the assessment and verification of eligibility for Health Insurance and Drug Benefit and administration of the Health Insurance and Ontario Drug Benefit Acts, and for health planning and coordination. It is collected/used for these purposes under the authority of the Ministry of Health Act, section 6(1,2), Health Insurance Act, section 4(2) (b,f), 10, 11(1), and Regulation 201/96 under the Ontario Drug Benefit Act, section 2. For information about collection practices, call 1 800 268-1154, in Toronto (416) 314-5518, or write to the Director, Registration and Claims Branch, P.O. Box 48, 49 Place d'Armes, Kingston ON K7L 5J3.