Form B "Seniors' Drug Plan Annual Application" - Saskatchewan, Canada

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Download Form B "Seniors' Drug Plan Annual Application" - Saskatchewan, Canada

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RETURN TO:
FORM B
Drug Plan & Extended Benefits Branch
3475 Albert Street
Regina, Saskatchewan
S4S 6X6
PHONE: 1-800-667-7581 or 306-787-3317
FAX: 306-787-8679
EMAIL: dpeb@health.gov.sk.ca
SENIORS’ DRUG PLAN
ANNUAL APPLICATION
Completing Side B means that you must apply for the program each year.
Provide a copy of your Notice of Assessment OR pages 1 to 4 of your Income Tax Return showing Line 236.
If you do not file income tax, please include a written explanation and provide all documentation from all sources of income.
(some examples: cheque stubs, T4 slips)
Please ensure you have provided all information. Incomplete applications will result in delays in processing.
Coverage is effective the date complete information is received, subject to approval.
APPLICANT
SURNAME
FIRST NAME
CURRENT ADDRESS
CITY
POSTAL CODE
DATE OF BIRTH (DD / MM / YYYY)
PHONE NUMBER
-
HEALTH SERVICES NUMBER (HSN)
SOCIAL INSURANCE NUMBER (SIN)
DECLARATION AND CONSENT
By completing this form, I declare that my income from Line 236 is less than the eligibility amount used for the
Provincial Age Tax Credit.
YES 
NO  If NO, please indicate reason for applying.
Is the Power of Attorney (POA) signing on behalf of the applicant?
YES 
NO 
If YES, then copies of the POA documents MUST be attached. NOTE: If a Trustee, Guardian or POA is signing for the Applicant a copy of the legal
document must be attached to this consent form. Due to the variety of POA documents, some may not be considered acceptable, such as POA
specific to or limited to a bank or financial institution.
“I declare that all the information I have provided is complete and correct in all respects and fully discloses my total income from all
sources. I further consent to the use of this information by Saskatchewan Health for the purpose of determining my entitlement for other
Health Care benefits or programs but will not be disclosed to any other person or organization without my approval.”
SIGNATURE OF APPLICANT
DATE
If applicable, SIGNATURE OF GUARDIAN / TRUSTEE / POWER OF ATTORNEY.
DATE
A Witness is necessary if Applicant signs with an “X” or a mark.
PLEASE PRINT YOUR NAME IF GUARDIAN / TRUSTEE / POWER OF ATTORNEY.
DAYTIME CONTACT NUMBER OF GUARDIAN / TRUSTEE / POWER OF ATTORNEY.
09/17
RETURN TO:
FORM B
Drug Plan & Extended Benefits Branch
3475 Albert Street
Regina, Saskatchewan
S4S 6X6
PHONE: 1-800-667-7581 or 306-787-3317
FAX: 306-787-8679
EMAIL: dpeb@health.gov.sk.ca
SENIORS’ DRUG PLAN
ANNUAL APPLICATION
Completing Side B means that you must apply for the program each year.
Provide a copy of your Notice of Assessment OR pages 1 to 4 of your Income Tax Return showing Line 236.
If you do not file income tax, please include a written explanation and provide all documentation from all sources of income.
(some examples: cheque stubs, T4 slips)
Please ensure you have provided all information. Incomplete applications will result in delays in processing.
Coverage is effective the date complete information is received, subject to approval.
APPLICANT
SURNAME
FIRST NAME
CURRENT ADDRESS
CITY
POSTAL CODE
DATE OF BIRTH (DD / MM / YYYY)
PHONE NUMBER
-
HEALTH SERVICES NUMBER (HSN)
SOCIAL INSURANCE NUMBER (SIN)
DECLARATION AND CONSENT
By completing this form, I declare that my income from Line 236 is less than the eligibility amount used for the
Provincial Age Tax Credit.
YES 
NO  If NO, please indicate reason for applying.
Is the Power of Attorney (POA) signing on behalf of the applicant?
YES 
NO 
If YES, then copies of the POA documents MUST be attached. NOTE: If a Trustee, Guardian or POA is signing for the Applicant a copy of the legal
document must be attached to this consent form. Due to the variety of POA documents, some may not be considered acceptable, such as POA
specific to or limited to a bank or financial institution.
“I declare that all the information I have provided is complete and correct in all respects and fully discloses my total income from all
sources. I further consent to the use of this information by Saskatchewan Health for the purpose of determining my entitlement for other
Health Care benefits or programs but will not be disclosed to any other person or organization without my approval.”
SIGNATURE OF APPLICANT
DATE
If applicable, SIGNATURE OF GUARDIAN / TRUSTEE / POWER OF ATTORNEY.
DATE
A Witness is necessary if Applicant signs with an “X” or a mark.
PLEASE PRINT YOUR NAME IF GUARDIAN / TRUSTEE / POWER OF ATTORNEY.
DAYTIME CONTACT NUMBER OF GUARDIAN / TRUSTEE / POWER OF ATTORNEY.
09/17