Application For Registration - Medicare - Service Nouveau-Brunswick
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Application for Registration - Medicare
P.O. Box 5100 Fredericton, N.B. E3B 5G8
Telephone: 1-888-762-8600 toll free or
Out of Province (506) 684-7901
I n d i v i d u a l s , w h o s e M e d i c a r e c a r d h a s e x p i r e d o r w a s
First and Last Name of Applicant Completing Form
t e r m i n a t e d m o r e t h a n 2 ye a r s a g o , m u s t r e a p p l y t o N . B .
M e d i c a r e a n d c o m p l e t e a n Ap p l i c a t i o n f o r R e g i s t r a t i o n
f o r m .
Current Residential
Apt #
Residential street # and name
Mailing address (if different than residential)
Address MUST
Be Provided
City, Town or Village
Province
Postal Code
City, Town or Village
Province
Postal Code
Telephone:
Home: (
)
Cellular: (
)
Work: (
)
Employer and/or occupation (if applicable):
IMPORTANT: All areas of this form MUST be completed. Incomplete forms will be returned. Refer to back of application for requirements.
Are you a/Have you:
New Resident
Returning Resident
Remained in NB, provide expiry date of Medicare Card: ___________________
Language Preference:
English
French
Marital Status:
Single
Married
Widowed
Separated
Divorced
Common-law
"Dependent" means a spouse or child living in New Brunswick who is:
(a) the spouse of a beneficiary if not maintaining a separate household, or
(b) an eligible beneficiary's child who is under the age of nineteen, unmarried and dependent for support upon the beneficiary, including an: adopted child;
a child to whom a person stands in loco parentis if that person's spouse is a parent of the child; a child whose parents are not married to one another.
"Child" means a child, step-child, legally adopted child or legal ward of a registrant who is (b).
List your name below as well as those of all your household members who have accompanied you to N.B.
Last Name
Preferred
Organ
Date of
Gender
Date Left N.B.
Date Of
NB Medicare number
First Name
Donor
Birth
M or F
(DD/MM/YY)
Permanent Move
(if applicable)
Y or N
(DD/MM/YY)
To N.B.
(DD/MM/YY)
Applicant
Spouse/Partner
Dependant
Dependant
Dependant
Dependant
Reason for absence from New Brunswick (if applicable):
Where did you arrive from? (Country, Province, Territory):
Have you applied for health coverage in another Province or Territory? Provide Health Insurance Number(s):
Yes
No
How long do you intend to stay in New Brunswick?
Permanently (over 1 year)
Temporarily (under 1 year)
Are you moving to NB for the purpose of attending school/university?
Yes
No
Name of Educational Institution:
Did your spouse and dependent children accompany you?
Yes
No
If no, provide date they are expected to join you
: ____________________
Where are they arriving from? _____________________________
(DD/MM/YY)
New Brunswick Medicare number of spouse:
Name of spouse prior to marriage:
If you (or spouse) are regular member(s) of the Armed Forces, please provide: Name of member(s):
Date(s) of Enlistment
:
Official Date(s) of Release
:
Province of Release:
(DD/MM/YY)
(DD/MM/YY)
If being released from a penal institution:
Federal
Provincial
Name of Institution:
Most Recent Date of Entry
___________________________
Date of Release
: ______________________________
(DD/MM/YY):
(DD/MM/YY)
State Province of Release:
Name of Released Member:
Have you and/or any member of your household left New Brunswick for over 30 days in the last 12 months?
Yes
No
If yes, provide name(s): __________________________________________________________________________________________________________
Date of departure
____________________ Date of return
____________________ Destination: __________________________
(DD/MM/YY):
(DD/MM/YY):
Reason for absence:
Additional Comments:
Resident Declaration – Please read carefully
The Medical Services Payment Act defines a resident as "a person lawfully entitled to be or to remain in Canada, who makes his home and is
ordinarily present in New Brunswick, but does not include a tourist, transient or visitor to the Province".
I, the applicant, hereby declare that I have read the definition of a "resident" and that the information given on this form is correct and that the
persons listed are permanent residents in accordance with the definition of a "resident".
Date:
Signature of Applicant:
Signature of Spouse/Partner:
140915 A-OTCE
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