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Visitor Information Center
Health, Seniors and Active Living
Manitoba.ca
>
Health, Seniors and Active Living
eNotice of Change
This form is to report the changes listed below. Please answer as many of these questions as you can
Reported Changes
I want to report the following changes:
Replacement Card
Change of Address
Moving Out of Manitoba
Removal of Dependant(s)
Registrant Information
Registration Number
Personal Health Identification Number
Home Phone Number
Business Phone Number
Mobile Phone Number
Last Name
First Name
Middle Name
(optional)
Sex
Male
Female
Date of birth
Current Address (the address that is on your Manitoba Health card):
Apartment/Unit Number
Street Number and Name/PO Box/RR/General Delivery Address
Street Type
Direction
E
N
NE
NW
S
SE
SW
W
City/Town/Municipality
Province
Postal Code
Change of Address
New Address:
Apartment/Unit Number
Street Number and Name/PO Box/RR/General Delivery Address
Street Type
Direction
E
N
NE
NW
S
SE
SW
W
City/Town/Municipality
Province
Postal Code
Is your mailing address different from your residential address?
Yes
No
>
Do you maintain a Saskatchewan mailing address?
Yes
No
New Mailing Address:
PO Box/RR/General Delivery Address
City/Town/Municipality
Province
Postal Code
New Mailing Address:
Apartment/Unit Number
Street Number and Name/PO Box/RR/General Delivery Address
Street Type
Direction
E
N
NE
NW
S
SE
SW
W
City/Town/Municipality
Province
Postal Code
Moving Out of Manitoba
Please make a selection:
To be completed by a) single persons b) families that leave Manitoba together
To be completed in cases where one spouse leaves Manitoba prior to his/her spouse and/or dependants
To be completed in cases where one spouse leaves Manitoba, and the remainder of the family remains in Manitoba
By completing this section, I am certifying that I and my dependants, if any, are leaving Manitoba permanently, as indicated below:
By completing this section, I am certifying that I am leaving Manitoba permanently and my dependant(s) are moving at a later date, as indicated below:
By completing this seciton, I am certifying that I am leaving Manitoa permanently as indicated below, and my dependant(s) will remain in Manitoba:
Date of Departure from Manitoba
Date of Arrival in New Place of Residence
Dependants Date of Departure from Manitoba
Dependants Date of Arrival in New Place of Residence
New Address:
Apartment/Unit Number
Street Number and Name/PO Box/RR/General Delivery Address
Street Type
Direction
E
N
NE
NW
S
SE
SW
W
City/Town/Municipality
Province, Territory or State if Applicable
Postal/Zip Code
Country
Is your mailing address different from your new residential address?
Yes
No
New Mailing Address:
Apartment/Unit Number
Street Number and Name/PO Box/RR/General Delivery Address
Street Type
Direction
E
N
NE
NW
S
SE
SW
W
City/Town/Municipality
Province, Territory or State if Applicable
Postal/Zip Code
Country
Removal of Dependant(s)
Reason for removing dependant(s):
Divorce/Separation
Death
Move minor dependant(s) to another Manitoba Health card
Divorce/Separation
Please enter your (ex) spouse's information below:
Last Name
First Name
Date of Birth
Date of Divorce
Do you know the address of your (ex) spouse?
Yes
No
Does your (ex) spouse still live in Manitoba?
Yes
No
Current Address of (ex) Spouse:
Apartment/Unit Number
Street Number and Name/PO Box/RR/General Delivery Address
Street Type
Direction
E
N
NE
NW
S
SE
SW
W
City/Town/Municipality
Province
Postal Code
Is your (ex) spouse's mailing address different from their residential address?
Yes
No
Does your (ex) spouse maintain a Saskatchewan mailing address?
Yes
No
Street Number and Name/PO Box/RR/General Delivery Address:
City/Town/Municipality:
Province:
Postal Code
Apartment/Unit Number
Street Number and Name/PO Box/RR/General Delivery Address
Street Type
Direction
E
N
NE
NW
S
SE
SW
W
City/Town/Municipality
Province
Postal Code
Current Address of (ex) Spouse:
Apartment/Unit Number
Street Number and Name/PO Box/RR/General Delivery Address
Street Type
Direction
E
N
NE
NW
S
SE
SW
W
City/Town/Municipality
Province, Territory or State if Applicable
Postal/Zip Code
Country
Death
Please provide the following information for the deceased
Last Name
First Name
Date of Birth
Date of Death
Move Minor Dependant to Another Manitoba Health Card
I would like to remove the following dependant from my Manitoba Health card:
Last Name
First Name
Middle Name
Sex
Male
Female
Date of birth
I would like to remove the following dependant from my Manitoba Health card:
Last Name
First Name
Middle Name
Sex
Male
Female
Date of birth
I would like to remove the following dependant from my Manitoba Health card:
Last Name
First Name
Middle Name
Sex
Male
Female
Date of birth
I would like to remove the following dependant from my Manitoba Health card:
Last Name
First Name
Middle Name
Sex
Male
Female
Date of birth
I would like to remove the following dependant from my Manitoba Health card:
Last Name
First Name
Middle Name
Sex
Male
Female
Date of birth
I would like to remove the following dependant from my Manitoba Health card:
Last Name
First Name
Middle Name
Sex
Male
Female
Date of birth
I would like to remove the following dependant from my Manitoba Health card:
Last Name
First Name
Middle Name
Sex
Male
Female
Date of birth
I would like to remove the following dependant from my Manitoba Health card:
Last Name
First Name
Middle Name
Sex
Male
Female
Date of birth
I would like to remove the following dependant from my Manitoba Health card:
Last Name
First Name
Middle Name
Sex
Male
Female
Date of birth
I would like to remove the following dependant from my Manitoba Health card:
Last Name
First Name
Middle Name
Sex
Male
Female
Date of birth
Are you sure you want to delete the last minor dependant added?
Please provide the information of the Manitoba Health card your minor dependant(s) is/are moving to:
Registration Number
Last Name of Primary Cardholder
First Name of Primary Cardholder
Sex
Male
Female
Cardholder's Relationship to Dependant(s)
Parent
Guardian
Aunt/Uncle
Other
Please Specify Relationship
Dependant's New Address
Apartment/Unit Number:
Street Number and Name/PO Box/RR/General Delivery Address
Street Type
Direction
E
N
NE
NW
S
SE
SW
W
City/Town/Municipality
Province
Postal Code
Is your dependant's mailing address different from their new residential address?
Yes
No
Do they maintain a Saskatchewan mailing address?
Yes
No
PO Box/RR/General Delivery Address
City/Town/Municipality
Province
Postal Code
Apartment/Unit Number
Street Number and Name/PO Box/RR/General Delivery Address
Street Type
Direction
E
N
NE
NW
S
SE
SW
W
City/Town/Municipality
Province
Postal Code
Form Completed By
Name
Cardholder's Relationship to Dependant(s)
Self
Spouse
Parent/Guardian
Power of Attorney
Other
Please Specify Relationship
Email Address
Date
This information is being collected so Manitoba Health can provide you with health coverage and service. All personal information is protected under the Personal Health Information Act. For more information about your personal information, call Manitoba Health at 786-7101 in Winnipeg or toll free at 1-800-392-1207, 830am to 430pm Monday thru Friday.
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