Addition of Spouse

Manitoba Health, Seniors and Long-Term Care

Addition of spouse

Addition of spouse
Supporting documentation

Note: In order to complete this form, you must download and print the PDF version of this form. Download the PDF form
Both spouses are required to sign it manually. Attach the completed and signed PDF with this form.

Cardholder's information

Registration number (six-digit alphanumeric)

Personal Health Identification Number (PHIN - nine digits)

Primary phone number

Email address

Legal first name

Legal middle name

Legal last name

Date of birth

Select either English or French as your official language

Current address

Apartment/unit number

Street address (or PO box number)

City

Province

Postal code

Is your mailing address the same as your current address?