Application For Health Coverage (Page 2 of 2) in pdf

APPLICATION FOR

NEWFOUNDLAND AND LABRADOR

HEALTH CARE COVERAGE

Health and Community Services

Medical Care Plan

SECTION A

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

1. Have you or your dependents been registered with MCP before?

 Yes

 No

If YES, please list on a separate sheet the previous MCP numbers (if available) of all persons to be registered.

2. When did you and/or your dependents move to Newfoundland & Labrador? ___________________________________________________

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

 Yes - Province/Territory ____________________

 No

4. Are you moving to Newfoundland & Labrador from outside Canada?

 Yes - Country ____________________

 No

5. Have you made a permanent move to Newfoundland & Labrador?

 Yes

 No - intended length of stay ________________________

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?

 Yes

 No - explain _____________________________

8. Are any of the applicants listed on this form a member of:

 Canadian Forces

 NATO Forces

 Part-time Reserve

Name of applicant(s) _______________________________________________________________________________________________

SECTION B

HOME MAILING ADDRESS

Street / P.O. Box

City / Town

Province

Postal Code

Home Telephone Number

Cell Number

E-mail Address

SECTION C

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

Single 

Married 

Common Law 

Separated 

Divorced 

Widowed 

LIST BELOW YOUR NAME AND THE NAMES OF ALL PERSONS REGISTERING FOR HEALTH CARE COVERAGE

SECTION D

(attach a separate sheet if more space required)

All Given Names

Birth Date

(in full)

Previous Province Health

Maiden Name

Gender

Surname

Insurance No.

(if applicable)

(M / F)

(if applicable)

(First Name)

(Middle Name)

(YYYY)

(MM)

(DD)

SECTION E

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: ________________________________________________________

Date: ___________________________

PRIVACY NOTICE

The Newfoundland and Labrador Medical Care Plan (MCP) 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 contact our office. The Department of Health and Community Services privacy statement can be found at

Grand Falls-Windsor Office:

St. John’s Office:

MCP, 22 High Street, PO Box 5000, Grand Falls-Windsor, NL, A2A 2Y4

MCP, 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