Re-Apply for the Ostomy Supplies Program | eServices Prince Edward Island

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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 PEI 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 or at the address on this form.

Identification

Please note: This webform is for renewal of coverage through the Ostomy Supplies Program only. First time applicants need to fill out the Ostomy Supplies Program Patient Application.

I confirm that I have filed my most recent PEI income tax return with the Canada Revenue Agency.

I confirm that I am currently enrolled in the Ostomy Supplies Program.

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

Are you a resident of a long-term care facility?

Do you have a spouse?

A spouse is a person who is your partner in a marriage or common-law union.