ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦ DEPARTMENT OF HEALTH MUNAQHILIQIYITKUT MINISTÈRE DE LA SANTÉ

ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦ DEPARTMENT OF HEALTH MUNAQHILIQIYITKUT MINISTÈRE DE LA SANTÉ




Applicant Information - Demandeur

ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦ DEPARTMENT OF HEALTH MUNAQHILIQIYITKUT MINISTÈRE DE LA SANTÉ

ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦ

Department of Health

Munaqhiliqiyitkut

Ministère de la Santé








Extended Health Benefits Application- Specified Condition



  1. Applicant Information



Surname Given Name(s)


Birthdate (d/m/y) HCP # (Health Care Number)


Mailing Address




____________________________________ ________________________________________________________

Home Phone e-mail Address


  1. Employment Status


Description


Applicant - Demandeur


Common-Law / Spouse - Conjoint


ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦ DEPARTMENT OF HEALTH MUNAQHILIQIYITKUT MINISTÈRE DE LA SANTÉ ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦ DEPARTMENT OF HEALTH MUNAQHILIQIYITKUT MINISTÈRE DE LA SANTÉ ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦ DEPARTMENT OF HEALTH MUNAQHILIQIYITKUT MINISTÈRE DE LA SANTÉ Are you employed?


ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦ DEPARTMENT OF HEALTH MUNAQHILIQIYITKUT MINISTÈRE DE LA SANTÉ Yes No


Yes No


If Yes, Name of Employer or Government Department.



ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦ DEPARTMENT OF HEALTH MUNAQHILIQIYITKUT MINISTÈRE DE LA SANTÉ



ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦ DEPARTMENT OF HEALTH MUNAQHILIQIYITKUT MINISTÈRE DE LA SANTÉ


Employer’s Phone number.


ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦ DEPARTMENT OF HEALTH MUNAQHILIQIYITKUT MINISTÈRE DE LA SANTÉ


ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦ DEPARTMENT OF HEALTH MUNAQHILIQIYITKUT MINISTÈRE DE LA SANTÉ


Do you have an Insurance Plan?


Yᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦ DEPARTMENT OF HEALTH MUNAQHILIQIYITKUT MINISTÈRE DE LA SANTÉ ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦ DEPARTMENT OF HEALTH MUNAQHILIQIYITKUT MINISTÈRE DE LA SANTÉ es No

Oui Non


ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦ DEPARTMENT OF HEALTH MUNAQHILIQIYITKUT MINISTÈRE DE LA SANTÉ ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦ DEPARTMENT OF HEALTH MUNAQHILIQIYITKUT MINISTÈRE DE LA SANTÉ Yes No

Oui Non

If Yes, Name of Plan.



ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦ DEPARTMENT OF HEALTH MUNAQHILIQIYITKUT MINISTÈRE DE LA SANTÉ



ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦ DEPARTMENT OF HEALTH MUNAQHILIQIYITKUT MINISTÈRE DE LA SANTÉ

ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦ DEPARTMENT OF HEALTH MUNAQHILIQIYITKUT MINISTÈRE DE LA SANTÉ See over – Box 6


  1. Medical Statement


__________________________________ _______________ _____________________________________

ICD9 Code or Description Date of Diagnosis Physician Name (Pease Print)


______________________________________________ _________________________

Signature (Physician or Nurse in Charge) Date













Medications including DIN# – to be completed by Physician or Nurse







Please note: For any changes or new prescriptions please advise EHB to ensure coverage.


  1. Employer Benefits Statement if applicable


Please attach a letter from your employer which confirms

a) you did not opt out of any group medical insurance plan OR

b) confirmation that prescription drugs, dental, medical supplies and equipment, vision care or medical travel (meals, accommodations, airfare) is not a benefit offered.





ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦ DEPARTMENT OF HEALTH MUNAQHILIQIYITKUT MINISTÈRE DE LA SANTÉ

See over







  1. Does your insurance plan cover any of the following?


1. A prescription drug plan:


If yes, please indicate level of coverage___________________________________________


2 Travel costs for medical reasons:


If yes, does this include meals & accommodation? __________________________________


3 Ambulance costs:

If yes, please indicate level of coverage___________________________________________

4. Dental Benefits:

If yes, please indicate level of coverage___________________________________________

5. Eyeglass Benefits:

If yes, please indicate level of coverage___________________________________________


6. Medical Equipment / Supplies:

If yes, please indicate level of coverage___________________________________________

7. A retirement group insurance plan:

If yes, please indicate level of coverage & benefits and start date of retirement benefits


_________________________________________________________________________


____________________________________________















  1. Medications (include DIN #) - To be completed by Physician or Nurse


















Applicant’s Declaration



I hereby certify that the information given is true, correct and complete to the best of my knowledge.



Signature: _______________________________________________________ Date: ______________________

(Applicant, Parent, or Guardian)






Please submit application via mail to:


Health Insurance Programs

Government of Nunavut

Box 889,

Rankin Inlet,

Nunavut X0C 0G0



OR Email to:


[email protected]



Phone 867-645-8029 Toll Free 1-800-661-0833 Fax 867-645-8092 e-mail: [email protected]






Tags: department of, ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦ, santé, munaqhiliqiyitkut, department, ministère, health