eNotice of Change | Health and Seniors Care

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) Change Sex Designation

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 Non-Binary

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

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

City/Town/Municipality

Province

Postal Code

Is your mailing address different from your residential address? Yes No

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

Date of Departure from Manitoba

Date of Arrival in New Place of Residence

Removal of Dependant(s)

Change Sex Designation

I would like to change my sex designation to: Male Female Non-Binary

Form Completed By

Name

Cardholder's Relationship to Dependant(s)

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.