Cra Consent Form

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NOVA SCOTIA SENIORS’ PHARMACARE PROGRAM
P.O. BOX 9322 HALIFAX, N.S., B3K 6A1 T
429-6565 or 1-800-544-6191 FAX (902)468-9402
ELEPHONE
Name: _____________________
Health Card Number:
_____________________
Address:
______________________________________
______________________________________
______________________________________
CRA CONSENT FORM
As a member of The Nova Scotia Seniors’ Pharmacare Program, you may be eligible for a reduced or
waived premium. To know if you are eligible, your income must be verified by the Canada Revenue
Agency (CRA). Please complete the consent form below and Pharmacare will get the income information
from CRA each year. At the beginning of each billing period, Pharmacare will send you a notice of any
premium owing.
Please note:
If you have a spouse, his/her signature and Social Insurance Number are required to
process this consent.
Income Verification Consent
I/we hereby consent to the release, by the Canada Revenue Agency, of information from my income tax
records to the Nova Scotia Department of Health, or its authorized representatives. This authorization is
valid for two taxation years prior to my signing the application and each subsequent consecutive taxation
year for which assistance is requested by me or on my behalf. This information will be relevant to and
used solely for the purpose of the general administration and enrollment in the Nova Scotia Seniors’
Pharmacare Program. This information will not be disclosed to any person, department or organization
without my approval. I understand if I wish to withdraw this authorization, I may do so at any time by
writing to the Seniors’ Pharmacare Program.
Signature of Applicant
Date
_________________________________________
Applicants Social Insurance Number
Signature of Spouse (if applicable)
Date
Spouse Health Card Number
Spouse Social Insurance Number
Please return this completed form to the Nova Scotia Seniors’ Pharmacare Program. A self addressed
envelope is enclosed.
Questions?
Call 429-6565 or 1-800-544-6191 and have your Nova Scotia Health Card Number
ready. Email us at
SeniorsPharmacare@medavie.bluecross.ca
and we will reply by
email.
CRA Consent Form 2011

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