Renew Eligibility for PEI Glucose Sensor Program and / or the PEI Insulin Pump Program

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Prefill with your MyPEI Account

Allow this form to use information already in your MyPEI account to fill in fields automatically. You can review and edit everything before submitting.

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?

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)

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?

Specify who you are applying for

What is the child/student's living arrangements?

Do you have a spouse?

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

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