Medicare P.O. Box 5100 Fredericton, N.B. E3B 5G8 Telephone: 1-888-762-8600 toll free or Outside North America (506) 684-7901
First and Last Name of Applicant Completing Form
CurrentResidential Apt # Residential street # and name Address MUST
Be Provided
City, Town or Village Postal Code
Telephone: Home: ( ) Cellular: ( ) Work: ( )
Mailing address (if different than residential)
City, Town or Village Postal Code
Employer and/or occupation (if applicable):
IMPORTANT: All areas of this form MUST be completed. Incomplete forms will be returned. Refer to back of application for requirements.
Are you a/Have you: New Resident Returning Resident Remained in NB, provide expiry date of Medicare Card: Language Preference: French
Marital Status: Single Married Divorced Common-law
"Dependent" means a spouse or child living in New Brunswick who is:
(a) thespouseofabeneficiaryifnotmaintainingaseparatehousehold,or
(b) an eligible beneficiary's child who is under the age of nineteen, unmarried and dependent for support upon the beneficiary, including an: adopted child;
a child to whom a person stands in loco parentis if that person's spouse is a parent of the child; a child whose parents are not married to one another. "Child" means a child, step-child, legally adopted child or legal ward of a registrant who is (b).
List your name below as well as those of all your household members who have accompanied you to N.B.
Individuals, whose Medicare card has expired or was terminated more than 2 years ago, must reappl y to N.B. Medicare and complete an Application for Registration form .
NB Medicare number (if applicable)
Last Name
Preferred First Name
Applicant Spouse/Partner Dependant Dependant Dependant Dependant
Reason for absence from New Brunswick (if applicable):
Where did you arrive from? (Country, Province, Territory):
Have you applied for health coverage in another Province or Territory? Yes No
Provide Health Insurance Number(s):
Organ Donor Y or N
Date of Birth (DD/MM/YY)
Date Left N.B. (DD/MM/YY)
Date of Permanent Move To N.B. (DD/MM/YY)
Gender
M/F/X
How long do you intend to stay in New Brunswick? Permanently (over 1 year)
Temporarily (under 1 year)
No NameofEducationalInstitution:
AreyoumovingtoNBforthepurposeofattendingschool/universityfulltime?
Yes
Did your spouse and dependent children accompany you?
If no, provide date they are expected to join you (DD/MM/YY):
New Brunswick Medicare number of spouse: Ifyou(orspouse)areregularmember(s)oftheArmedForces,pleaseprovide: Nameofmember(s):
Date(s) of Enlistment (DD/MM/YY): Official Date(s) of Release (DD/MM/YY): Province of Release:
Yes No
Name of spouse prior to marriage:
Where are they arriving from?
If being released from a penal institution:
Most Recent Date of Entry (DD/MM/YY): State Province of Release:
Federal
Provincial Name of Institution:
Date of Release (DD/MM/YY): Name of Released Member:
Have you and/or any member of your household left New Brunswick for over 30 days in the last 12 months? Yes No If yes, provide name(s):
Date of departure (DD/MM/YY): Date of return (DD/MM/YY): Destination:
Reason for absence:
Additional Comments:
Resident Declaration – Please read carefully
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".
Date: Signature of Applicant: Signature of Spouse/Partner:
35-5012 050820 A-OCE
New Brunswick Medicare Card Application
The primary requirement for provincial health benefits is permanent residence in New Brunswick. A resident is a person who is legally entitled to remain in Canada and who makes his home and is ordinarily present in the Province, but does not include a tourist, transient or visitor to the Province.
It is an offense to knowingly obtain or aid another person in obtaining insured services to which she/he is not entitled.
Required Documentation for Registration
To process your application for New Brunswick Medicare, you must provide photocopies of documents supporting:
Status in Canada, Identity and Residency
One document is required from List 1 & 2 for each individual listed on the Application form.
A copy of the last entry date stamp in the passport for each individual is required for those arriving from outside of Canada.
AND
One document is required from List 3 for Applicant completing the form.
Please Note: The same document may not be used to satisfy more than one requirement
Do not send original documents as we cannot guarantee their safe return
If documentation from each category below is not submitted, the application will not be processed
Applications are assessed on a case by case basis; additional information may be required upon review
List 1 Status in Canada
(New Brunswick Medicare will not determine an individual’s citizenship or status in Canada on behalf of Citizenship and Immigration Canada)
Canadian: Birth Certificate; Canadian Passport; Canadian Citizenship Card; Certificate of Canadian Citizenship; Canadian Native Status Card.
Non-Canadian: Valid Permit; Confirmation of Valid Permanent Residence or Permanent Resident Card (front & back) issued by Citizenship and Immigration Canada
List 2 Support of Identity
Document that displays your name such as:
• Birth Certificate
• Valid New Brunswick Driver’s License
• ValidPassport(Canadianorforeign)
• BaptismalCertificate(ifplaceanddateofbirthindicated)
• Valid Permanent Resident Card (front & back) or Record of Landing Document (Form # IMM 1000)
• ActiveTemporaryResidentPermitissuedbyCitizenshipand Immigration Canada
(does not ensure eligibility for NB Medicare)
• Certificate of Canadian Citizenship
• CanadianNativeStatusCard(front&back)
• Legal Name Change Document
• StudentorEmployeeIDCard
• PreviousProvincialHealthCard
•
•
•
• • • • •
List 3
Proof of Residency in New Brunswick
Document must be current and display applicant's name and NB address as provided to Medicare, such as:
Mortgage Document
Rental or Lease Agreement
(must be at least a 1 year term and signed by the landlord & tenant)
Utility Bill - not older than 2 months
(phone, energy, cable/satellite, water/sewer)
Employment Confirmation
(pay stub or letter from employer on company letterhead)
Insurance Policy (home, tenant, auto) Valid NB Motor Vehicle Registration Valid NB Driver's License
Child Tax Benefit Statement
Property Tax Bill (current year)
PLEASE REVIEW THE FOLLOWING TO AVOID DELAYS IN PROCESSING YOUR REQUEST
Do not send original documents as we cannot guarantee their safe return.
It is important to provide a contact number should Medicare need to contact you.
Your current residential address must be provided even if your mailing address is different.
You cannot apply for New Brunswick Medicare prior to your arrival to New Brunswick.
If previously registered with Medicare under a different name, please include name as it was previously registered in the "Additional Comment" section.
A separate application for registration must be completed for all child nineteen years of age or older. If you are completing this form on behalf of an individual (not a dependant), who is 19 years of age or older, a copy of Power of Attorney documents must be provided.
NB residents who provide out of country birth certificates, must provide Canadian Immigration Records or proof of Canadian Citizenship. Medicare will not determine citizenship for individuals on behalf of Citizenship and Immigration Canada.
Discrepancies with Permanent Resident documents or Temporary Resident Permits are the responsibility of the applicant and Citizenship and Immigration Canada.
Read and sign the "Resident Declaration" upon completion of the form.
Signature of applicant (person completing form) and spouse/partner (if arriving with you) is required.
Please allow four to six weeks, upon receipt by Medicare, for processing your application.
If you require assistance or have questions with respect to this form, please contact Service New Brunswick’s Teleservices toll free # at 1-888-762-8600 or go to:
www.gnb.ca/health
Completed application forms may be mailed to the address on the front of the application form or delivered in person to any Service New Brunswick office. Medicare processes original applications only. Applications that are faxed or copied will not be processed.
The Department of Health collects the personal information required on this form for the purposes of assessing and
