"Saskatchewan Health Services Card Application" - Saskatchewan, Canada

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Saskatchewan Health Services Card Application
Health Services Card Information
Who should apply? All new residents of Saskatchewan must
When will I be eligible? A person’s benefits may begin on different
register themselves and their dependants under 18 years of age
dates depending on circumstances. A Saskatchewan health
for a Saskatchewan health services card in order to be eligible for
services card is mailed to each family member just prior to the
health benefits.
effective date if the application has been approved. For more
information, please visit the website:
Can I apply online for a health card? You can apply online at:
www.ehealthsask.ca/HealthRegistries/Pages/health-benefits.aspx
www.ehealthsask.ca/HealthRegistries/Pages/apply-for-health-
card.aspx
Can I register all family members or do they need to register
individually? You may register yourself, your spouse/partner
Who is eligible for Saskatchewan health benefits? If you are a
and all dependants that are living with you in Saskatchewan.
Canadian Citizen or Permanent Resident, make your home in
Dependents 18 years of age or older must complete their own
Saskatchewan and you ordinarily live in the province at least
application.
6-months in a 12-month period or if you are a special class of
newcomers and move to Saskatchewan from outside Canada,
Students (Temporary Residents in Saskatchewan)
you may be eligible for Saskatchewan Health benefits. For more
If you are an international student temporarily residing in
information, please visit the website:
Saskatchewan to further your education you may be eligible for
Saskatchewan Health benefits. For more information, please visit
www.ehealthsask.ca/HealthRegistries/Pages/health-benefits-
eligibility.aspx
the website:
www.ehealthsask.ca/HealthRegistries/Pages/health-
benefits-eligibility.aspx
For more information, please refer to Frequently Asked Questions at:
www.ehealthsask.ca/HealthRegistries/Pages/benefits-questions.aspx
Required Documentation
In order to process your application for a Saskatchewan Health Services Card, you must include photocopies (front and back, if applicable)
of documents proving your 1) Legal Entitlement to be in Canada, 2) Saskatchewan Residency, and 3) Support of Identity.
• One document from each category listed below is required for the applicant and spouse/partner on this application.
• One document from 1) Legal Entitlement to be in Canada and 3) Support of Identity is required for each dependant on this application.
Some examples of acceptable documents are listed below. The required documents must accompany your application. Please do not send
original documents as we cannot guarantee their safe return. For a complete listing of eligible documentation, refer to the back page of this form.
**The same document may NOT be used to satisfy more than one requirement.
1) Legal Entitlement to be in Canada
2) Saskatchewan Residency
3) Support of Identity
A valid document to prove you are
A valid document that displays your name
A valid document that displays your name
a Canadian Citizen or hold another
and current home address and confirms
(and may include signature), such as:
immigration status that makes you eligible
that your primary place of residence is in
• Previous provincial health card
for Saskatchewan health benefits, such as:
Saskatchewan, such as:
• Saskatchewan driver’s licence or
Canadian Citizens
• Signed mortgage, rental, or lease
temporary driver’s licence
• Birth Certificate from a
agreement.
• Passport
Canadian province or territory
• Utility bill (home telephone, cable TV,
• Birth Certificate
• Canadian Passport
satellite TV, water, gas , or energy)
• Permanent Resident Card (front & back)
• Certificate of Indian Status
• Insurance policy (home, tenant, or auto)
• Certificate of Canadian Citizenship
• Certificate of Canadian Citizenship or
• Saskatchewan Motor Vehicle
• Certificate of Indian Status
Certificate of Naturalization
Registration
• Confirmation of Permanent Residence
• Employer record (pay stub or letter
• Student ID card
Permanent Residents/Landed Immigrants
from employer on company letterhead)
• Employee ID
• Permanent Resident Card (front & back)
• Income tax assessment
• Baptismal Certificate
• Confirmation of Permanent Residence
• Property tax bill
• Immunization record
• Canadian Immigration Identification Card
• School, college or university
Foreign Nationals
report card or transcript
• Study Permit (Confirmation of full-time
enrollment is required)
• Work Permit
• Foreign Passport with Immigration Stamp
• Temporary Resident Permit
A complete list of documents is available at:
www.ehealthsask.ca/HealthRegistries/Pages/health-card-supporting-doc.aspx
1
Saskatchewan Health Services Card Application
Health Services Card Information
Who should apply? All new residents of Saskatchewan must
When will I be eligible? A person’s benefits may begin on different
register themselves and their dependants under 18 years of age
dates depending on circumstances. A Saskatchewan health
for a Saskatchewan health services card in order to be eligible for
services card is mailed to each family member just prior to the
health benefits.
effective date if the application has been approved. For more
information, please visit the website:
Can I apply online for a health card? You can apply online at:
www.ehealthsask.ca/HealthRegistries/Pages/health-benefits.aspx
www.ehealthsask.ca/HealthRegistries/Pages/apply-for-health-
card.aspx
Can I register all family members or do they need to register
individually? You may register yourself, your spouse/partner
Who is eligible for Saskatchewan health benefits? If you are a
and all dependants that are living with you in Saskatchewan.
Canadian Citizen or Permanent Resident, make your home in
Dependents 18 years of age or older must complete their own
Saskatchewan and you ordinarily live in the province at least
application.
6-months in a 12-month period or if you are a special class of
newcomers and move to Saskatchewan from outside Canada,
Students (Temporary Residents in Saskatchewan)
you may be eligible for Saskatchewan Health benefits. For more
If you are an international student temporarily residing in
information, please visit the website:
Saskatchewan to further your education you may be eligible for
Saskatchewan Health benefits. For more information, please visit
www.ehealthsask.ca/HealthRegistries/Pages/health-benefits-
eligibility.aspx
the website:
www.ehealthsask.ca/HealthRegistries/Pages/health-
benefits-eligibility.aspx
For more information, please refer to Frequently Asked Questions at:
www.ehealthsask.ca/HealthRegistries/Pages/benefits-questions.aspx
Required Documentation
In order to process your application for a Saskatchewan Health Services Card, you must include photocopies (front and back, if applicable)
of documents proving your 1) Legal Entitlement to be in Canada, 2) Saskatchewan Residency, and 3) Support of Identity.
• One document from each category listed below is required for the applicant and spouse/partner on this application.
• One document from 1) Legal Entitlement to be in Canada and 3) Support of Identity is required for each dependant on this application.
Some examples of acceptable documents are listed below. The required documents must accompany your application. Please do not send
original documents as we cannot guarantee their safe return. For a complete listing of eligible documentation, refer to the back page of this form.
**The same document may NOT be used to satisfy more than one requirement.
1) Legal Entitlement to be in Canada
2) Saskatchewan Residency
3) Support of Identity
A valid document to prove you are
A valid document that displays your name
A valid document that displays your name
a Canadian Citizen or hold another
and current home address and confirms
(and may include signature), such as:
immigration status that makes you eligible
that your primary place of residence is in
• Previous provincial health card
for Saskatchewan health benefits, such as:
Saskatchewan, such as:
• Saskatchewan driver’s licence or
Canadian Citizens
• Signed mortgage, rental, or lease
temporary driver’s licence
• Birth Certificate from a
agreement.
• Passport
Canadian province or territory
• Utility bill (home telephone, cable TV,
• Birth Certificate
• Canadian Passport
satellite TV, water, gas , or energy)
• Permanent Resident Card (front & back)
• Certificate of Indian Status
• Insurance policy (home, tenant, or auto)
• Certificate of Canadian Citizenship
• Certificate of Canadian Citizenship or
• Saskatchewan Motor Vehicle
• Certificate of Indian Status
Certificate of Naturalization
Registration
• Confirmation of Permanent Residence
• Employer record (pay stub or letter
• Student ID card
Permanent Residents/Landed Immigrants
from employer on company letterhead)
• Employee ID
• Permanent Resident Card (front & back)
• Income tax assessment
• Baptismal Certificate
• Confirmation of Permanent Residence
• Property tax bill
• Immunization record
• Canadian Immigration Identification Card
• School, college or university
Foreign Nationals
report card or transcript
• Study Permit (Confirmation of full-time
enrollment is required)
• Work Permit
• Foreign Passport with Immigration Stamp
• Temporary Resident Permit
A complete list of documents is available at:
www.ehealthsask.ca/HealthRegistries/Pages/health-card-supporting-doc.aspx
1
Saskatchewan Health Services Card Application
Section A.
Applicant Personal Information
Important:
Before you continue, please ensure you attach a photocopy (front and back, if applicable)
of ONE document from EACH of the following categories:
1) Legal Entitlement to be in Canada 2) Saskatchewan Residency 3) Support of Identity
Applicant Information
Applicant Citizenship
My last name is:
Canadian Citizen
Permanent Resident (Landed Immigrant)
My first name(s):
Work Permit
My middle
Study Permit (Confirmation of
name(s):
full-time enrollment is required)
My birth date is:
Graduation Date
YYYY–MM–DD
YYYY–MM–DD
Other (specify):
Male
Female
My sex is:
Why are you applying?
Never Married
Married
My marital
I am applying because I am:
Common Law
Separated
status is:
Divorced
Widowed
A new Saskatchewan resident
An existing Saskatchewan resident
My Indian Status
Registry Number
Health Services Number:
is:
(if applicable)
A returning Saskatchewan resident
My current mailing address is:
I departed Saskatchewan on:
YYYY–MM–DD
(if applicable)
Street:
My previous last name was:
City/Town:
My previous first name was:
Province/Territory:
My previous middle name was:
Postal Code:
Canadian Armed Forces or Federal Institution
I was discharged on:
My current residence address is:
YYYY–MM–DD
Street:
Applicant Details
City/Town:
I established residence
in Saskatchewan on:
Province/Territory:
YYYY–MM–DD
Postal Code:
I arrived in Canada on:
(if applicable)
or Land Location:
YYYY–MM–DD
(1/4 Section, Section, Township, Range, W-)
My last place of residence was:
Applicant Contact Details
My previous provincial
health card number:
My cell phone number is:
I am committed to being physically
Yes
No
present in Saskatchewan for at least
My home phone number is:
6-months in a 12-month period.
My work phone number is:
If you answered No, explain and state how long
you intend to reside in Saskatchewan:
My email address is:
Please complete all required information. Applications that are not complete may be returned.
2
Saskatchewan Health Services Card Application
Section B.
Spouse/Partner Personal Information
Important:
Before you continue, please ensure you attach a photocopy (front and back, if applicable)
of ONE document from EACH of the following categories:
1) Legal Entitlement to be in Canada 2) Saskatchewan Residency 3) Support of Identity
Spouse/Partner Information
Applicant Citizenship
My last name is:
Canadian Citizen
Permanent Resident (Landed Immigrant)
My first name(s):
Work Permit
My middle
Study Permit (Confirmation of
name(s):
full-time enrollment is required)
My birth date is:
Graduation Date
YYYY–MM–DD
YYYY–MM–DD
Other (specify):
Male
Female
My sex is:
Why are you applying?
Never Married
Married
My marital
I am applying because I am:
Common Law
Separated
status is:
Divorced
Widowed
A new Saskatchewan resident
An existing Saskatchewan resident
My Indian Status
Registry Number
Health Services Number:
is:
(if applicable)
A returning Saskatchewan resident
My current mailing address is the same as the applicant.
I departed Saskatchewan on:
Yes
No
YYYY–MM–DD
If No, my current mailing address is:
(if applicable)
My previous last name was:
Street:
My previous first name was:
City/Town:
My previous middle name was:
Canadian Armed Forces or Federal Institution
Province/Territory:
Postal Code:
I was discharged on:
My current residence address is the same as the applicant.
YYYY–MM–DD
Yes
No
If No, my current residence address is:
Applicant Details
Street:
I established residence
City/Town:
in Saskatchewan on:
YYYY–MM–DD
Province/Territory:
Postal Code:
I arrived in Canada on:
(if applicable)
or Land Location:
YYYY–MM–DD
(1/4 Section, Section, Township, Range, W-)
My last place of residence was:
Spouse/Partner Contact Details
My previous provincial
health card number:
My cell phone number is:
I am committed to being physically
Yes
No
present in Saskatchewan for at least
My home phone number is:
6-months in a 12-month period.
My work phone number is:
If you answered No, explain and state how long
you intend to reside in Saskatchewan:
My email address is:
Please complete all required information. Applications that are not complete may be returned.
3
Saskatchewan Health Services Card Application
Section C.
Dependant Personal Information
Before you continue, please ensure you attach a photocopy (front and back, if applicable) of ONE
Important:
document from EACH of the following categories: 1) Legal Entitlement to be in Canada 2) Support of Identity
Persons 18 years of age and older must complete a separate application
First Dependant Information
Second Dependant Information
My dependant’s last name is:
My dependant’s last name is:
My dependant’s first name(s):
My dependant’s first name(s):
My dependant’s middle name(s):
My dependant’s middle name(s):
My dependant’s birth date is:
My dependant’s birth date is:
YYYY–MM–DD
YYYY–MM–DD
Male
Female
Male
Female
My dependant’s sex is:
My dependant’s sex is:
My dependant’s Indian status
My dependant’s Indian status
registry number is:
registry number is:
(if applicable)
(if applicable)
My dependant’s mailing address
My dependant’s mailing address
Mine
Spouse/Partner
Mine
Spouse/Partner
is the same as:
is the same as:
(check only one)
(check only one)
My dependant’s residency address
My dependant’s residency address
Mine
Spouse/Partner
Mine
Spouse/Partner
is the same as:
is the same as:
(check only one)
(check only one)
First Dependant Citizenship
Second Dependant Citizenship
My dependant is a:
My dependant is a:
Canadian Citizen
Canadian Citizen
Permanent Resident (Landed Immigrant)
Permanent Resident (Landed Immigrant)
Work Permit
Work Permit
Study Permit (Confirmation of
Study Permit (Confirmation of
full-time enrollment is required)
full-time enrollment is required)
Graduation Date
Graduation Date
YYYY–MM–DD
YYYY–MM–DD
Other (specify):
Other (specify):
First Dependant Details
Second Dependant Details
Is a:
Is a:
A new Saskatchewan resident
A new Saskatchewan resident
A returning Saskatchewan resident
A returning Saskatchewan resident
Who established residence
Who established residence
in Saskatchewan on:
in Saskatchewan on:
YYYY–MM–DD
YYYY–MM–DD
Who arrived in Canada on:
Who arrived in Canada on:
(if applicable)
(if applicable)
YYYY–MM–DD
YYYY–MM–DD
Who is committed to being physically
Who is committed to being physically
Yes
No
Yes
No
present in Saskatchewan for at least
present in Saskatchewan for at least
6-months in a 12-month period.
6-months in a 12-month period.
If you answered No, explain and state how long he/she
If you answered No, explain and state how long he/she
intends to reside in Saskatchewan:
intends to reside in Saskatchewan:
Last place of residence was:
Last place of residence was:
Previous provincial health card number:
Previous provincial health card number:
Please complete all required information. Applications that are not complete may be returned.
4
Saskatchewan Health Services Card Application
Section C.
Dependant Personal Information (continued)
Important:
Before you continue, please ensure you attach a photocopy (front and back, if applicable) of ONE
document from EACH of the following categories: 1) Legal Entitlement to be in Canada 2) Support of Identity
Persons 18 years of age and older must complete a separate application
Third Dependant Information
Fourth Dependant Information
My dependant’s last name is:
My dependant’s last name is:
My dependant’s first name(s):
My dependant’s first name(s):
My dependant’s middle name(s):
My dependant’s middle name(s):
My dependant’s birth date is:
My dependant’s birth date is:
YYYY–MM–DD
YYYY–MM–DD
Male
Female
Male
Female
My dependant’s sex is:
My dependant’s sex is:
My dependant’s Indian status
My dependant’s Indian status
registry number is:
registry number is:
(if applicable)
(if applicable)
My dependant’s mailing address
My dependant’s mailing address
Mine
Spouse/Partner
Mine
Spouse/Partner
is the same as:
is the same as:
(check only one)
(check only one)
My dependant’s residency address
My dependant’s residency address
Mine
Spouse/Partner
Mine
Spouse/Partner
is the same as:
is the same as:
(check only one)
(check only one)
Third Dependant Citizenship
Fourth Dependant Citizenship
My dependant is a:
My dependant is a:
Canadian Citizen
Canadian Citizen
Permanent Resident (Landed Immigrant)
Permanent Resident (Landed Immigrant)
Work Permit
Work Permit
Study Permit (Confirmation of
Study Permit (Confirmation of
full-time enrollment is required)
full-time enrollment is required)
Graduation Date
Graduation Date
YYYY–MM–DD
YYYY–MM–DD
Other (specify):
Other (specify):
Third Dependant Details
Fourth Dependant Details
Is a:
Is a:
A new Saskatchewan resident
A new Saskatchewan resident
A returning Saskatchewan resident
A returning Saskatchewan resident
Who established residence
Who established residence
in Saskatchewan on:
in Saskatchewan on:
YYYY–MM–DD
YYYY–MM–DD
Who arrived in Canada on:
Who arrived in Canada on:
(if applicable)
(if applicable)
YYYY–MM–DD
YYYY–MM–DD
Who is committed to being physically
Who is committed to being physically
Yes
No
Yes
No
present in Saskatchewan for at least
present in Saskatchewan for at least
6-months in a 12-month period.
6-months in a 12-month period.
If you answered No, explain and state how long he/she
If you answered No, explain and state how long he/she
intends to reside in Saskatchewan:
intends to reside in Saskatchewan:
Last place of residence was:
Last place of residence was:
Previous provincial health card number:
Previous provincial health card number:
Please complete all required information. Applications that are not complete may be returned.
If you have more than four dependants, please list their information on the Additional Dependant Form.
5
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