Current Page 1 Page 2 Preview Personal information on this form is collected under section 31(c) of Prince Edward Island’s Freedom of Information and Protection of Privacy (FOIPP) Act as it relates directly to and is necessary for providing services under the Drug Cost Assistance Act. If you have any questions about this collection of personal information, you may contact the program office at 902-368-4947 or 1-877-577-3737. Identification Please note: Individuals that have private drug insurance are not eligible for the Generic Drug Program. I certify that I do not have private drug insurance. I certify that I am a permanent Prince Edward Island resident: I do not have a temporary resident visa, study permit, work permit or other similar visa or permit issued by Citizenship and Immigration Canada. First Name Middle Initial Last Name Address 1 Address 2 City, Town, or Community Province Postal Code For example: C1B 0X1 or 12345 Country Telephone Number For example 902-555-5555 Email Address Personal Health Number (PHN) Please enter the 8-digits from your PEI health card. Date of Birth You must be under the age of 65 to apply. Is your spouse included in your application? If your spouse has private insurance, he/she is not eligible for coverage provided by the Generic Drug Program. - Select -YesNo