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 PEI Drug Cost Assistance Act. If you have any questions about this collection of personal information, you may contact the program office at 902-213-4825 or 1-833-335-0538 or at the address on this form. Identification This webform is only to renew your eligibility for diabetes coverage each year. First you must apply and be approved for eligibility through the Glucose Sensor Program and/or the Insulin Pump Program. Which program are you renewing? - Select -Glucose Sensor ProgramInsulin Pump (Under 25 Years Old)Both (Under 25 Years Old) 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 Glucose Sensor Program and/or the Insulin Pump Program. Enter information for the individual who requires the glucose sensor and/or the insulin pump in the fields below. For dependants under 19, use their primary address. 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 the PEI health card of the individual who requires the glucose sensor and/or the insulin pump. Date of Birth Who are you applying for? - Select -MyselfOn behalf of a child or full-time student under the age of 25 What is the child/student's living arrangements? - Select -Two Parents/GuardiansOne Parent/GuardianOther Social Insurance Number (SIN) Do you have a spouse? A spouse is a person who is your partner in a marriage or common-law union. - Select -YesNo Are you a resident of a long-term care facility? - Select -YesNo