Sample OHIP Application Form
Sample OHIP Application Form[1]
|A. Personal Information |
|Last Name |First Name |Middle Name |Sex |
| | | |Male Female |
|Date of Birth (year/month/day) |Language Preference |Have you ever had on Ontario |If Yes, what number? |
| | |Health Number? | |
| |English French |Yes No | |
|Home Telephone No. | No phone |Work or other telephone no |
|( ) | |( ) |
|Have you recently left the Canadian Forces, RCMP, or a federal |If yes, were you discharged? (y/m/d) |
|penitentiary? Yes No | |
|B. Mailing Address |
|Street no. and name, P.O. box no., R. R., General Delivery |Apartment no. |
|City |Province |Postal Code |Country |
|C. Residence address if different from mailing address |
|Street no. and name, lot, concession, township |Apartment |City |Province |Postal Code |
| | | |ON | |
|D. Residence in Ontario |
|Have you lived in Ontario since birth? Yes No |How long do you plan to live in Ontario? Permanently |Are you a student? Yes No |
|If No, complete this section. If Yes, go to section E. |( Until | |
|Where did you move from? (Student number and name) |Apartment |City |Province |Country |
|When did you move to Ontario? (y/m/d) |When did you leave the above address? (y/m/d) |Former telephone no. |
| | | |
| | |( ) |
|If you moved from another part of Canada, were you covered by a government health |If Yes, what was your health number? |
|plan? Yes No | |
|Are you a Canadian Citizen returning to Canada? |Are you an immigrant returning to Canada? Yes |Are you a new immigrant? |
|Yes No |No |Yes No |
|E. Citizenship Status |
| |
|Canadian Citizen Aboriginal Landed Immigrant Convention Refugee Other |
|F. Agreement |
|I confirm that: |
|-I make my permanent and principal home in Ontario. |
|-I will be living in Ontario for at least 6 months (183 days) in the 12-month period immediately after this application. |
|-If there is a change in name, address, immigration, or citizenship status, I must tell the Ministry of Health within 30 days of the change. |
|-The information I have given in this application, and in the documents I have provided, is true and accurate. |
|-The Ministry of Health may check my resident status and any information I have given in this form and in the documents I have provided. |
|I understand that: |
|-For verification, this form may be collected from, and disclosed to, government and non-government organizations if the law allows it. |
|Signature of applicant |Date |
|parent | |
|legal guardian | |
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[1] Queen’s Printer for Ontario, 1999. Reproduced with permission from
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