Divorce Separation

Manitoba Health, Seniors and Long-Term Care

Divorce/separation

Divorce/separation
Supporting documentation

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

*

Sex

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?

Will you require a change of address?

Mailing address

Apartment/unit number

*

Street address (or PO box number)

*

City

*

Province

Postal code

*

New residential address

Apartment/unit number

*

Street address (or PO box number)

*

City

*

Province

Postal code

*

Is the new mailing address the same as the new residential address?

New mailing address

Apartment/unit number

*

Street address (or PO box number)

*

City

*

Province

Postal code

*

Type of card

Select the type of card

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