Nova Scotia Family Pharmacare Program Registration Form
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1
2Health Card Number: ______ _____ _____
Nova Scotia Family Pharmacare Program
Registration Form
Please read reverse side of this form to see who to include as family members.
Mail the completed form to the address on the reverse side of form.
FAMILY INFORMATION (please print clearly)
Include all family members (see reverse), even if they have drug coverage through other programs. All family members are
included in the copayment and deductible calculations. If more space is required attach a separate sheet.
LAST NAME
FIRST NAME
MIDDLE
DATE OF BIRTH
HEALTH CARD NUMBER
SOCIAL INSURANCE NUMBER
INITIAL
(YYYY/MM/DD)
Family Applicant:
/
/
Family Address
Telephone Number
Current Marital Status:
Married \ Common Law
Single
\ Widow
Family City/Town
Prov
Postal Code
NS
Divorced \ Separated
Spouse:
/
/
Children:
/
/
Children:
/
/
Children:
/
/
CONSENT
I/we hereby consent to the release, to the Nova Scotia Department of Health by the Canada Revenue Agency, of information from my
income tax returns and other required taxpayer information and, if applicable, information from my spouse’s and children’s in come tax
returns. This information will be relevant to and used solely for the purpose of determining and verifying eligibility for and the general
administration and enforcement of the Nova Scotia Family Pharmacare Program, and will not be disclosed to any person without my
approval. This consent is valid for the most recent tax year filed and assessed.
I understand that, if I wish to withdraw this
.
authorization, I may do so at any time by writing to the Family Pharmacare Program
Signature of Applicant
Date
Signature of Spouse (if applicable)
Date
DECLARATION
I declare that all the information I have provided in this form is complete and I understand that a false statement constitutes fraud and
may result in recovery of any benefits paid by the Nova Scotia Department of Health.
Signature of Applicant
Date
Signature of Spouse (if applicable)
Date
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