Click here to access the form
fill this Forman print it and sign it
this form will in the following format
Registrant Information
Last name:
First name:
Middle name:
Sex:
Male Female Non-Binary
Date of birth:
Marital Status:
Last name at birth:
Home phone number:
Business phone number:
Mobile number:
Registrant’s Residence and Citizenship/Immigration Information
Have you had Manitoba Health coverage before?
Yes No
Indian Status Registry Number (If Applicable):
Band name (If Applicable):
Are you or your spouse a member of the Canadian Armed Forces?
Yes No
Child Information
List only those members of the family who live in Manitoba.
Address
Home Address:
Apartment/unit number:
Street number and name/PO box/RR/general delivery address:
Street Type
Direction
City/town/municipality:
Province
Postal Code:
Is your mailing address different from your home address?
Yes No
Do all registrants intend to become permanent residents of Manitoba?
Yes No
If you have Canadian Citizenship, Permanent Resident Status, or have been issued a Work Permit by Immigration, Refugees and Citizenship Canada (IRCC) , attach a COPY as PROOF of your status in Canada. Proof of status is required for all family members applying. Proof of eligible status can be a valid Canadian:
Passport, Permanent Resident Document/Card (both sides), Birth Certificate, Citizenship Card or Treaty Card. Work Permit (Issued for 12 months or longer), or
Seasonal Agriculture Workers: Work Permit and a letter from the employer outlining employment dates.
If you are a spouse (common-law) or an underage dependant of a registrant who holds a Work Permit, attach a copy of your valid Canadian Visitor/Study Permit (Issued for six months or longer).
Proof of residence in the province is required, please view acceptable documents here .
By checking this box I acknowledge that I have read and understood the documents required to apply for Manitoba Health Coverage
Form Completed By
Name:
Relationship to applicant: Select… Self Spouse Parent/Guardian Power of Attorney Other
Email Address:
Authorization
Signature of Registrant
Date:
By checking this box I certify that the information contained herein is true. Section 42 of the Health Services Insurance Act provides for a fine of up to $5000 for a person convicted of making false and misleading statements.
make sure to sign this form after printing
as you can see in the for all required documents are listed you must provide just photocopies not the original one
and once that is done
Please submit completed and signed applications and supporting documents to:insuredben@gov.mb.ca
Incomplete or unsigned forms will be returned. Forms will not be processed without required documentation.
If you and your family are not eligible for Manitoba Health benefits you will be advised, otherwise, your Manitoba Health card will be mailed to your address.
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