M Registration 261h3w

Health and Community Services

APPLICATION FOR NEWFOUNDLAND AND LABRADOR HEALTH CARE COVERAGE

Medical Care Plan

PLEASE READ THE FOLLOWING INFORMATION BEFORE COMPLETING THE APPLICATION ON THE REVERSE

   

If you are applying for coverage with the Newfoundland and Labrador Medical Care Plan (M) you must complete this form. If you are applying for coverage for a newborn or adopted child, please complete the Newborn/Adopted Child Registration form. All forms are available on the website at www.gov.nl.ca/m and by calling M at one of the numbers listed at the bottom of this page. There are no charges or fees for M cards.

DOCUMENTS YOU MUST SUBMIT WITH THIS APPLICATION Canadian Citizens moving to Newfoundland and Labrador must provide one of the following documents: • Social Insurance Card. • Valid Canadian port. • Government issued Birth Certificate. (Baptismal/Dedication Certificates are not acceptable) • Federal Government document containing your name and social insurance number. (Example: Assessment from Revenue Canada) Non-Canadians moving to Newfoundland and Labrador must provide the following documents: • Immigration document valid for at least one year. (Example: Work Permit; Study Permit; Visitor Permit). • Valid port. • Letter from University or Employer (issued since your arrival in Newfoundland and Labrador) ing full-time enrolment or employment for at least one year. OR • Permanent Resident Card. (A copy of both the front and back of the card is required.) Other documents may be requested by M at the time of registration in order to identity or eligibility. Original documents or good quality photocopies are acceptable. Original documents will be returned after your application has been processed. M will not be responsible for original documents that may get lost in the mail. INELIGIBLE APPLICANTS The following persons are not eligible for M coverage: • Tourists, transients, and visitors. • of the Canadian Forces or NATO Forces. • Inmates of Federal prisons. • Certified refugees or refugee claimants. • Persons moving temporarily to Newfoundland and Labrador for a period of less than one year. WAITING PERIOD If you are moving permanently to Newfoundland and Labrador from another province or territory you will be covered by your previous Plan for the remainder of the month you arrived in Newfoundland and Labrador, plus two additional months. In order to allow sufficient time for a smooth change in coverage from your previous Plan to M, you should apply for coverage with M immediately upon arrival in Newfoundland and Labrador. HEALTH CARE CARDS If eligible for coverage, each person listed on the application will receive an M identity number and card. Keep the card with you at all times and present it each time you require medical services. M if your card becomes lost, stolen, damaged, or destroyed. Card replacement forms are also available at doctors’ offices and hospitals throughout the province. IT IS IMPORTANT THAT YOU NOTIFY M OF CHANGES TO YOUR NAME, ADDRESS, OR RESIDENCY STATUS

Grand Falls-Windsor Office: St. John’s Office: M, 22 High Street, PO Box 5000, Grand Falls-Windsor, NL, A2A 2Y4 M, 45 Major's Path, PO Box 8700, St. John’s, NL, A1B 4J6 Telephone: 709-292-4000 Toll Free: 1-800-563-1557 Facsimile: 709-292-4052 Telephone: 709-758-1600 Toll Free: 1-866-449-4459 Facsimile: 709-758-1694 www.gov.nl.ca/m

APPLICATION FOR NEWFOUNDLAND AND LABRADOR HEALTH CARE COVERAGE

Health and Community Services

SECTION A

Medical Care Plan

ANSWER ALL OF THE FOLLOWING QUESTIONS (please print) (see reverse for required documentation)

1.

Have you or your dependents been ed with M before?  Yes ✔  No If YES, please list on a separate sheet the previous M numbers (if available) of all persons to be ed.

2.

June 17, 2014 When did you and/or your dependents move to Newfoundland & Labrador? ___________________________________________________

3.

Are you moving to Newfoundland & Labrador from another part of Canada?

4.

Are you moving to Newfoundland & Labrador from outside Canada?

5.

Have you made a permanent move to Newfoundland & Labrador?

6.

Why did you move to Newfoundland & Labrador?  Work  Study ✔  Medical Intern/Resident  Other ________________________

7.

Have all of your dependents moved with you to Newfoundland & Labrador?

8.

Are any of the applicants listed on this form a member of:  Canadian Forces  NATO Forces  Part-time Reserve No Name of applicant(s) _______________________________________________________________________________________________

SECTION B Street / P.O. Box City / Town

✔  No

2 years  No - intended length of stay ________________________ ✔

 Yes

 Yes

No Dependents

 No - explain _____________________________

69A Great Eastern Ave Province

Home Telephone Number

SECTION C

SECTION D Surname

Newfoundland and Labrador

Cell Number

Postal Code

A1B 0C6

E-mail Address

[email protected]

MARITAL STATUS - If your spouse (legal or common law) is not already ed, s/he must also at this time.

Single ✔

SECTION E

 Yes - Country ____________________

 No

HOME MAILING ADDRESS

St. John's

Naik

Ontario ✔  Yes - Province/Territory ____________________

Married 

Common Law 

Separated 

Divorced 

Widowed 

LIST BELOW YOUR NAME AND THE NAMES OF ALL PERSONS ING FOR HEALTH CARE COVERAGE (attach a separate sheet if more space required) All Given Names (in full)

Maiden Name

(First Name)

(Middle Name)

(if applicable)

Neil

Pravinkumar

-

Birth Date

(M / F)

(YYYY)

(MM)

(DD)

Previous Province Health Insurance No. (if applicable)

M

1990

02

05

7412453230DE

Gender

DECLARATION (to be signed by parent/legal guardian if applicant(s) under 16 years of age)

IT IS AN OFFENCE TO GIVE FALSE INFORMATION FOR THE PURPOSE OF OBTAINING COVERAGE UNDER THE NEWFOUNDLAND & LABRADOR MEDICAL CARE PLAN

I hereby declare that the information given is correct and the person(s) listed on this form are residents of Newfoundland and Labrador. Signature of Applicant: ________________________________________________________

June 26, 2014 Date: ___________________________

PRIVACY NOTICE The Newfoundland and Labrador Medical Care Plan (M) collects personal health information under the authority of the Medical Care Insurance Act, 1999. Personal health information collected, used, disclosed, and safeguarded is in accordance with the Personal Health Information Act (PHIA). If you have any questions about the collection or use of this information please our office. The Department of Health and Community Services privacy statement can be found at www.health.gov.nl.ca/health/PHIA.

St. John’s Office: Grand Falls-Windsor Office: M, 22 High Street, PO Box 5000, Grand Falls-Windsor, NL, A2A 2Y4 M, 45 Major's Path, PO Box 8700, St. John’s, NL, A1B 4J6 Telephone: 709-292-4000 Toll Free: 1-800-563-1557 Facsimile: 709-292-4052 Telephone: 709-758-1600 Toll Free: 1-866-449-4459 Facsimile: 709-758-1694 www.gov.nl.ca/m