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

Health Number Release

This form may be submitted to the Ministry of Health and Long-Term Care when the Health Number of a patient is not available.

Confidential when completed

Ministry Use Only


1 Patient

A. General Information



Sex





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

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


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



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.

1265-84 (00/08)
7530-4626