Health Card Renewal - Nova Scotia

Fillable Printable Health Card Renewal - Nova Scotia

Health Card Renewal - Nova Scotia

HEALTH CARD

RENEWAL

Firs t Name

Middle Name

Last Name

Health Card Number

Date of Birth Day Mont h Year

Gender

Home Phone Number

Wor k Phone Number

Female Male ( ) ( )

Mailing Addr ess

City

Province

Postal Code

Residential Address (if different)

Community

Has your address recently changed? Yes No If so, is this a complete family move? Yes No

I certify that I am a permanent resident of Nova Scotia. (A permanent r esi dent i s a person who makes his/her

home and is ordinarily present in Nova Scotia.)

I authorize any health service provider paid by Medical Services Insurance (MSI) to release any information

requested by MSI for claims payment and audit.

Signature (A parent/guardian must sign f or dependants under the age of 16)

Date

YOUR ORGAN AND/O R TI SSUE DONOR DECISION MUST ALSO BE RENEWED.

You now have t he opportunity to offer someone a second c hance at life by becoming an organ and/or tissue donor.

Please consider this option and if you are int erested, com plete and sign the f orm below. Ident ification as a Donor will

appear on your new Health Card. The inf ormat ion below will be stored in a computerized donor registry.

Please specify which organ(s) and/or tissue(s) you wish to donate:

ALL organ(s) and tissue(s) needed for transpl ant

ONLY the following organ(s) and/or tissue(s) nee ded for transplant

Organs:

Tissues:

Lungs

Skin

Heart

Vein

Liver

Eyes

Kidneys

Bone & Related Structures

Pancreas

Heart Valves/Pericardium

Small Bowel

For information about organ donation, please call: 902-473-5523 or toll-free 1-877-841-3929.

For information about tissue donation, please call: 902-473-4171 or toll-free 1-800-314-6515.

Your signature is required

for organ and/or tissue donation. A parent/guardian must sign for dependants

under the age of 16. Consent to organ and/or tissue donation is voluntary and is not required for Health

Card eligibilit y.

Signature

Date

PLEASE FAX TO MSI REG I STR ATION AND ENQUIRY AT 90 2 -481-3160

Or mail to: NOVA SCOTIA MSI, PO BOX 500, HALIFAX, NS B3J 2S1

PHONE 902-496-7008 (1-800-563-8880)

Please note this form cannot be submitted online.

November 2014