Medicare Change Request, Replacement And/or Renewal Form
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Medicare Change Request, Replacement and/or Renewal
S e e i n s t r u c t i o n s o n b a c k o f f o r m f o r r e q u i r e m e n t s
P.O. Box 5100, Fredericton, N.B. E3B 5G8
C h e c k a n d c o m p l e t e a p p r o p r i a t e a r e a s
Telephone: 1-888-762-8600 (toll free)
S E C T I O N A
I n d i c a t e m e m b e r s a f f e c t e d b y c h a n g e s i n s e c t i o n A a n d / o r B
S E C T I O N A
Address
Marriage
Separation/
Death
Name
Misprinted Name/
Newborn
Adoption
Change
Divorce
Change
Date of Birth
of birth
Applicant - Individual
First Name
Middle Name
Family Name
Interoffice
Completing Form
Use Only
Status
Organ
English
Gender
Y
1
Date of Birth
DD
MM
YY
Medicare #
F
Preferred
Donor
Language
N
French
M
2
Spouse/Partner Name
DD
MM
YY
Medicare #
Organ
Gender
English
F
Y
Preferred
Donor
Language
N
French
M
3
Dependent Name
DD
MM
YY
Medicare #
Organ
Gender
Y
English
F
Preferred
Donor
Language
N
French
M
4
Dependent Name
DD
MM
YY
Medicare #
Organ
Gender
Y
English
F
Preferred
Donor
Language
French
M
N
5
Dependent Name
DD
MM
YY
Medicare #
English
Organ
F
Y
Gender
Preferred
Donor
Language
French
M
N
:
Requested
Previous Name(s):
New Name(s):
M
Apt #
Residential street # and name
Mailing address (if different than residential)
Current
Residential
Address MUST
City, Town or Village
Province
Postal Code
Be Provided
Telephone Numbers:
Home (
)
Cell (
)
Work (
)
English
Additional Comments:
S E C T I O N B
French
Replacement Card - One card per person only.
Do not send cash by mail. Non-refundable $10 fee required for each card, unless you are a recipient of:
Guaranteed Income Supplement
Income Assistance
Received damaged or misprinted card
S E C T I O N B
Name(s) of individual(s) requiring card: ____________________________________________________________________________________________
English
Reason for request:
Lost
Theft
Damaged
Other (clarify): ____________________________________________________________
Please Note: If you report your card stolen, a replacement card fee of $10 is applicable. For privacy purposes, the stolen card will be terminated. A
new Medicare number and card will be issued upon receipt of the fee. It is your responsibility to notify your service providers of your new number.
French
________________________
Expired Card or Renew Coverage - Provide expiry date as it appears on Medicare card (
):
MM/YYYY
Expired cards or coverage that has been terminated within the last 24 months, requires physical presentation (exceptions may apply) at a local SNB Centre to
provide proof of identity and residency. The same document may not be used to satisfy more than one requirement. If you have left NB for 30 days or more,
complete the temporarily absent section below.
Individuals, whose Medicare card has expired or was terminated more than 2 years ago, must reapply to N.B. Medicare and complete an Application for
Registration form.
Immigration Renewal Document – copy of extended permit(s) or front and back of Permanent Resident Card(s).
Federal Penitentiary
Date of Entry
: _________________________ Name: _______________________________________________
(DD/MM/YY)
Name of Institution:
(If being released, please complete an Application for Registration form).
Armed Forces
Date of Entry
: _____________________ (If being released, please complete an Application for Registration form)
(DD/MM/YY)
Names(s):
Out of Province/Country Move? Please Contact: 1-888-762-8600
Out of Province Student (must contact Medicare yearly)
Out of Country Student (must supply proof of enrollment)
Leave Date
Return Date
Name(s):
(DD/MM/YY): ___________________
(DD/MM/YY): ____________________
______________________________________________
Educational Institution:
Out of province/country address:
Vacation/Visit Temporarily Absent (Outside New Brunswick)
Business Temporarily Absent (Outside New Brunswick)
Temporary vacation/visit absence status for a NB eligible resident is defined as a period of absence from NB, for up to 212 days in a 12 month period. Those
who exceed 212 vacation/visit days (consecutive or not) require the Director's approval.
Temporary absence for business purposes cannot exceed 182 days in a 12 month period (consecutive or not).
Approval may be granted for a duration of up to 12 months only once per 3 years from the time of return (vacation/visit or business purposes). If exceeding 12
months, NB resident must reapply for NB Medicare.
Mobile Worker (Outside New Brunswick)
Requesting to extend Medicare eligibility for up to 2 years, due to employment which requires frequent travel outside NB, a letter, including dates of rotation,
must be provided by the employer and/or resident confirming frequent travel is required outside NB.
Contract Worker (Outside Canada)
Status may be assigned for up to a maximum of 2 years. A copy of your contractual agreement must be provided which identifies your start and end date of
employment.
(DD/MM/YY): _______________
(DD/MM/YY): _______________
_________________________________________
Leave Date
Return Date
Destination:
_____________________________________________________________________________________________________________________
Name(s):
____________________________________________________________________________________________________________
Forwarding address:
Reason for absence:
RESIDENCY DECLARATION
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”.
Applicant's Signature:
Date:
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