Change of Address

Manitoba Health, Seniors and Long-Term Care

Change of address

Change of address
Form completed by

Cardholder's information

Registration number (six-digit alphanumeric)

*

Personal Health Identification Number (PHIN - nine digits)

*

Primary phone number

*

Email address

**

Can we contact you at this email address?

Legal first name

*

Legal middle name

*

Legal last name

*

Date of birth

*

New address

Apartment/unit number

*

Street address (or PO box number)

*

City

*

Province

Country

Postal code

*

Is your mailing address the same as your new address?

New mailing address

Apartment/unit number

*

Street address (or PO box number)

*

City

*

Province

Country

Postal code

*

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