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MSI Health Card Renewal Form

This document is a health card renewal form for a resident of Nova Scotia. It requests information such as name, address, date of birth, and contact details to renew a health card. It specifies that a birth certificate must be provided if the date of birth on file is incorrect. It also contains an optional section for the applicant to register as an organ and/or tissue donor, with details on the types of organs or tissues they agree to donate. Signatures are required to authorize the release of medical information and to register as a donor if chosen.

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2K views1 page

MSI Health Card Renewal Form

This document is a health card renewal form for a resident of Nova Scotia. It requests information such as name, address, date of birth, and contact details to renew a health card. It specifies that a birth certificate must be provided if the date of birth on file is incorrect. It also contains an optional section for the applicant to register as an organ and/or tissue donor, with details on the types of organs or tissues they agree to donate. Signatures are required to authorize the release of medical information and to register as a donor if chosen.

Uploaded by

dohudohu2
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd

HEA CARD HEA HEALTH CARD RENEWAL

FULL HEALTH
NAME: _____________________________________________________ CARD #: __________________________
{Given Name(s) & Surname}

MAILING ADDRESS (including Postal Code):

Street/PO Box/RR# ___________________________________________________ GENDER (M/F): _____________

City/Town/Village/Postal Code____________________________________ DATE OF BIRTH:___________________
(Day/Month/Year)

HOME ADDRESS ( if different from above):

Street/Apt#____________________________________________________ HOME PHONE #___________________

Community Name ______________________________________________ WORK PHONE # __________________


PLEASE NOTE: IF THE BIRTHDATE ON YOUR HEALTH CARD IS WRONG, YOU MUST PROVIDE A COPY OF
YOUR BIRTH CERTIFICATE. ALSO, IF YOUR ADDRESS HAS CHANGED, PLEASE SPECIFY IF
IT IS NOT A COMPLETE FAMILY MOVE.

I CERTIFY THAT I AM A PERMANENT RESIDENT OF NOVA SCOTIA. (A PERMANENT RESIDENT IS A PERSON
WHO MAKES HIS/HER HOME AND IS ORDINARILY PRESENT IN NOVA SCOTIA.)
I AUTHORIZE ANY HEALTH SERVICE PROVIDER PAID BY MEDICAL SERVICES INSURANCE (MSI) TO
RELEASE ANY INFORMATION REQUESTED BY MSI FOR CLAIMS PAYMENT AND AUDIT.

_________________________________________________________________________________________________________________________
SIGNATURE (A Parent/Guardian must sign for dependants under the age of 16) DATE


YOUR ORGAN AND/OR TISSUE DONOR DECISION MUST ALSO BE RENEWED.

ORGAN and TISSUE DONATION GIVING LIFE
You now have the opportunity to offer someone a second chance at life by becoming an organ and/or tissue donor.
Please consider this option and if you are interested, complete and sign the form below.
Identification as a Donor will appear on your new Health Card (and must be reconfirmed during the renewal process).
The information below will be stored in a computerized donor registry.
For donor program information, please call: (902) 473-5523 or toll-free 1-877-841-3929.
Please specify which organ(s) and/or tissue(s) you wish to donate:

ALL organ(s) and tissue(s) needed for transplant, OR ONLY the following organ(s) and/or tissue(s) needed for transplant

ORGANS: Lungs Heart Liver Kidneys Pancreas Small Bowel
TISSUES: Skin Vein Corneas (eyes) Bone & Related Structures Heart Valves/Pericardium

Your signature is required for organ and/or tissue donation. A parent/guardian must sign for dependants under the
age of 16. Consent to organ and/or tissue donation is voluntary and is not required for Health Card eligibility.

DATE:: _________________________________ Signature: __________________________________________________

For Health Card information, call MSI at: (902) 496-7008 or toll-free (in NS) at: 1-800-563-8880.

PLEASE FAX TO MSI REGISTRATION AND ENQUIRY AT (902) 481-3160
NOVA SCOTIA MSI, PO BOX 500, HALIFAX, NS B3J 2S1
PHONE (902) 496-7008 (1-800-563-8880)
(RE-013) June 2012

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