PEI Health Card Application for New Residents 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), Section 31 (c) of the Freedom of Information and Protection of Privacy Act and under Section 17 (1) of the Health Information Act, 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.Providing race and ethnicity information is voluntary and is not required for Health Card eligibility or access to health services in PEI. By choosing to provide this information, you consent to its collection and use for the purposes of health services planning, service delivery, and monitoring health outcomes to address equity gaps. This data will not be shared with hospitals, doctors, or nurse practitioners for use in daily practice or displayed on your health card. You may update your race and ethnicity information at any time by submitting a Notice of Change to Race and Ethnicity Data to PEI Medicare.Intent to donate organ and/or tissue and language profile responses are voluntary and are not required for Health Card eligibility. 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/Legal Guardian Last Name of Accompanying Parent/Legal Guardian Accompanying Parent/Legal Guardian's Personal Health Number (PHN) Enter the 8-digits from the PEI health card Place of Birth Country and Province (if applicable) Sex - 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. Which race and/or ethnicity category(ies) best describes you? In our society, people are often described by their race or racial background. These are not based in science, but our race may influence the way we are treated by individuals and institutions, and this may affect our health.Check all that apply. Black (e.g., African, African Canadian, Afro-Caribbean descent) East Asian (e.g., Chinese, Hong Kong, Japanese, Korean, Taiwanese descent) Indigenous (e.g., First Nations, Métis, Inuk/Inuit descent) Latin American (e.g., Hispanic or Latin American descent) Middle Eastern (e.g., Arab, Persian, Afghan, Egyptian, Iranian, Kurdish, Lebanese, Turkish) South Asian (e.g., Bangladeshi, Indian, Indo-Caribbean, Pakistani, Sri Lankan) Southeast Asian (e.g., Cambodian, Filipino, Indonesian, Thai, Vietnamese) White (e.g., European descent) Do not know Prefer not to answer Another Race Category Another race category, please specify. 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 MarinoSarkSaudi 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 CunhaTunisiaTurkmenistanTurks & Caicos IslandsTuvaluTürkiyeU.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. Intention to be an Organ and Tissue Donor The information below will be stored in a secure computerized PEI Intent to Donate Registry. In the future, your intention to donate organs and/or tissues will be displayed on your new PEI Health Card. I intend to donate organs needed for transplant This includes lungs, heart, liver, kidneys, pancreas, small bowel. - Select -YesNo I intend to donate tissues needed for transplant This includes skin, eyes, bone and related structures, heart valves/pericardium. - Select -YesNo By checking this box, I am declaring that I am 16 years of age or over, or that I am the parent or legal guardian of a person age 15 or younger. 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?
