Current Page 1 Page 2 Page 3 Preview Personal information on this form is collected under Section 8 (Registration of Entitled Persons) of Prince Edward Island’s Health Services Payment Act (Regulations) and will be used to ensure a resident’s entitlement in respect to basic health services. If you require additional information, please contact Medicare Services, 126 Douses Road, Montague, PE C0A 1R0, 1-800-321-5492. Identification Use your current mailing address in the fields below. 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 Confirm Email Address Date of Birth Are you 16 years of age or older? - Select -YesNo First Name of Accompanying parent Last Name of Accompanying Parent Accompanying Parent's Personal Health Number (PHN) Please enter the 8-digits from your PEI health card. Place of Birth Country and Province (if applicable) Gender - Select -MaleFemaleOther Citizenship Status - Select -Canadian CitizenCanadian citizen returning from another countryPermanent ResidentInternational StudentWorking Visa Note: You are required to submit a verification letter for your proof of current enrollment from your school, along with a copy of your Study Permit and Passport, before your application will be processed. Previous Residence Was your previous residence within Canada? - Select -YesNo Previous Residence - Select -AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta & MelillaChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d’IvoireDenmarkDiego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard & McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorth MacedoniaNorwayOmanOutlying OceaniaPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. HelenaSt. Kitts & NevisSt. LuciaSt. MartinSt. Pierre & MiquelonSt. Vincent & GrenadinesSudanSurinameSvalbard & Jan MayenSwedenSwitzerlandSyriaSão Tomé & PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis & FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Address 1 Address 2 City, Town, or Community Province Postal Code For example C1B 0X1 or 12345 Country Residential Status If you have previously lived on PEI and held a valid health card, then please select 'Returning Resident to PEI' from the dropdown. - Select -New ResidentReturning Resident to PEIArmed ForcesPenitentiary Please indicate release date Date of arrival on Prince Edward Island Reason for coming to Prince Edward Island - Select -Student/InternshipEmploymentOther Other, please specify Canadian students continue to receive health coverage under their home province while studying in PEI. Contact your home province for more information. Have you recently graduated from a PEI post-secondary institution? - Select -YesNo Graduation Date Are you enrolled as a full-time or part-time student/intern? - Select -Full-timePart-time Estimated graduation date Length of stay on Prince Edward Island - Select -PermanentTemporary How long will you be living on PEI? You must be living on PEI for at least 6 months and 1 day to qualify for a healthcard. Organ and Tissue Donor Decision The information below will be stored in a secure computerized PEI Donor Registry. In the future, your organ and/or tissue donor decision will be displayed on your new Health Card. For more information about organ and tissue donation, please call: 902-368-5920. I wish to donate organs needed for transplant. This includes lungs, heart, liver, kidneys, pancreas, small bowel. - Select -YesNo I wish to donate tissues needed for transplant This includes skin, eyes, bone and related structures, heart valves/pericardium. - Select -YesNo Language Profile In order to plan for service delivery, please answer the following questions related to your language profile. Your preferred language of service will be displayed on your new Health Card. If you would like a Unilingual French card please feel free to contact the Medicare Office at 1-800-321-5492. What is your mother tongue? The language you first learned in childhood and still understand. If your mother tongue is neither English nor French, in which of Canada's official languages are you most comfortable? - Select -EnglishFrenchNeither What is your preferred language for service delivery?