Medicare Change Request, Replacement And/or Renewal Form Page 2

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Medicare Change Request, Replacement and/or Renewal

Instructions

Any person who violates or assists a person in violating the residency requirements is guilty of an offense and liable to either a

fine and/or imprisonment.

It is your responsibility to keep your Medicare file up to date. Use this form to report any changes to your household.

Medicare renewal for expired cards or coverage that has been terminated within the last 24 months requires physical presentation (exceptions

may apply) at a Service New Brunswick Centre, to provide proof of Identity (from list 1) and Residency (from list 2).

The same document may NOT be used to satisfy more than one requirement. Please do not send original documents as we cannot guarantee

their safe return.

All forms are processed on a case by case basis; additional information may be required upon review.

List 1 – Support of Identity

List 2 – Proof of Residency in New Brunswick

Document that displays your name, such as:

Document must be current and display applicant's name and New

Brunswick address as provided to Medicare, such as:



Birth Certificate

Mortgage Document



Valid New Brunswick Driver’s License

Rental or Lease Agreement

(must be at least a 1 year term and signed by the landlord & tenant)



Passport (Canadian or foreign)



Utility Bill - no older than 2 months



(phone, energy, cable/satellite, water/sewer)

Baptismal Certificate (if place and date of birth is indicated)



Employment Confirmation - current

Permanent Resident Card (front & back) or Record of Landing Document

(Form # IMM 1000)

(pay stub or letter from employer on company letterhead)



Active Temporary Resident Permit issued by Citizenship and Immigration

Insurance Policy (home, tenant or auto)

Canada (does not ensure eligibility for NB Medicare)



Valid New Brunswick Motor Vehicle Registration



Certificate of Canadian Citizenship



Valid New Brunswick Driver's License



Certificate of Native Status (front & back)



Child Tax Benefit Statement



Legal Name Change Document



Property Tax Bill



Student or Employee ID Card



Previous Provincial Health Card

Please complete an Application for Registration form if you or a member of your household:



Moved from New Brunswick and are returning.



Have not previously applied for New Brunswick Medicare (new resident).



The expiry date on your Medicare card is over 2 years.

In an effort to avoid delays in processing, the following instructions provide general information to assist you in making requests to Medicare. Please allow 4 to

6 weeks from the day of receipt to process your request. All forms are processed on an individual basis and additional documents may be required. New

Brunswick Medicare has the right to terminate your coverage or adjust your expiry date at any time.

Address Change:



If your mailing address is a: P.O. Box, Rural Route, or General Delivery; you must also provide your residential (physical) address.



Indicate all members affected by address change in Section A of this form.



Provide apartment # if applicable.

Marriage:



Provide spouse’s name, date of birth and Medicare number.



Include dependents accompanying spouse. A copy of legal custody documents may be required.



If name change required provide: former name, chosen (married) name, Medicare number and copy of marriage certificate.

Separation/Divorce:



Indicate with whom dependents are residing, if applicable. A copy of legal custody documents may be required.



Provide identifying information on ex-spouse: name, date of birth, Medicare number and address (if known).



If changing name, see below “Name Change”.

Name Change:



If returning to previous birth last name, copy of birth certificate is required if not born in NB. If born in NB, indicate this on form and provide name as

it appears on the birth certificate.



Last name change due to marriage requires a copy of the marriage certificate.



First or last name change for reasons other than above, require a copy of the legal name change document.

Incorrect Date of Birth or Name:



Copy of birth certificate or valid Canadian passport required if born in another Province. If born in New Brunswick, indicate this on form and provide

name as it appears on the birth certificate.



If not born in Canada, provide a copy of your Canadian Immigration document. Names will only be corrected as they appear on Canadian

Immigration documents.

Additional Eligible Household Member (Newborn, Adoption or Minor Dependant):



Power of Attorney documents are required if you are completing this form on behalf of a current eligible NB resident who is over the age of 19.



If you wish to add a dependant to your household who is under the age of 19, legal custody documents are required.



To add an adopted a child (born in NB) to your household, please provide proof of Canadian Citizenship and legal adoption documents. If the child

was not born in New Brunswick, an Application for Registration form must be completed and required documents provided.

Please sign the “Resident Declaration” upon completion of the form.

If you require assistance or have questions with respect to this form, please feel free to contact Service New Brunswick’s Teleservices toll free number at 1-

888-762-8600 or go to:

Completed forms may be mailed to the address on the front of the form (with the exception of forms for expired or terminated coverage, as stated above) or

delivered in person to any Service New Brunswick Centre. Medicare requires the original Change Request, Replacement and/or Renewal form (exceptions

may apply).

The Department of Health collects the personal information required on this form for the purposes of assessing and processing your requests to

Medicare and is committed to safeguarding your privacy.

For more information on our privacy practices and about your rights regarding this issue, go to:

110915CE