Privacy Notice

The Manitoba Department of Health, Seniors and Long-Term Care (the Department) is authorized to collect your personal information and personal health information on this form pursuant to clauses 36(1)(a) and (b) of The Freedom of Information and Protection of Privacy Act, CCSM c F175 (FIPPA), subsection 13(1) of The Personal Health Information Act, CCSM c P33.5 (PHIA), and section 37 of The Health Services Insurance Act, CCSM c H35. This collection is for the following purposes:

• processing this application for registration, request for temporary out-of-province benefits or notice of change under the Manitoba Health Services Insurance Plan (the Plan);
• determining, verifying, suspending or cancelling eligibility for the Plan;
• administering, monitoring and evaluating the Plan, including investigating fraud relating to payment for health care;
• producing and issuing registration certificates under the Plan; and
• researching, planning and reporting purposes, and for compliance with legislated obligations.

Any other use of your personal information or personal health information by the Department must be authorized by FIPPA and/or PHIA. If you have any questions about the collection of your personal information or personal health information, please contact the Insured Benefits Branch at 204-786-7101 or toll free 1-800-392-1207.

Consent

By submitting this application, you consent to the indirect collection, use and disclosure of your personal information and personal health information (and if applicable, that of your dependants and/or anyone for whom you are a lawful representative) when necessary for the purposes outlined above, between the following persons/entities and the Manitoba Department of Health, Seniors and Long-Term Care (the Department), its agents and service providers:

• Federal, provincial, and municipal government departments, agencies, Crown Corporations, service providers and other third parties including, but not limited to, the Manitoba Department of Consumer Protection and Government Services, Shared Health, health authorities, medical practitioners, hospitals, surgical facilities, the Public Guardian and Trustee, law enforcement agencies, the Office of the Chief Medical Examiner, the Manitoba Public Insurance Corporation, and organizations engaged to produce and/or issue registration certificates.

The collection and disclosure of your personal information and personal health information will be limited to the minimum amount of information reasonably necessary to accomplish the purpose of the collection or disclosure.

Your consent is voluntary and can be withdrawn at any time, but withdrawal may result in a denial of coverage under the Manitoba Health Services Insurance Plan.