Fillable Family Pharmacare Registration Form

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Family Pharmacare Registration Form

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Country of origin: CANADA
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Form 599 April 2019
Health Card Number:
FAMILY PHARMACARE PROGRAM
PO BOX 500 Halifax NS B3J 2S1 Telephone 902-496-5667 or 1-877-330-0323 Fax 902-468-9402
Registration Form
• Please read reverse side of this form to see who to include as family members.
• Please sign both the Consent and Declaration below.
• Mail the completed form to the address on the reverse side of form.
FAMILY INFORMATION (please print clearly)
Include all family members (see reverse), even if they have drug coverage through other programs. All family members are
included in the copayment and deductible calculations. If more space is required, please attach a separate sheet.
Please provide your family’s contact information:
Street Address
City/Town
Province
NS
Postal Code
Phone Number:
Current Marital Status:
Married\Common Law
Single
\Widow
Divorced\Separated
Please list all family members:
Last Name First Name
Date of Birth
(dd/mm/yyyy)
Health Card Number
Social Insurance Number
(for Applicant and Spouse)
Applicant:
/ /
Spouse:
/ /
Children:
/ /
Not Required
Children:
/ /
Children:
/ /
CONSENT
I/we hereby consent to the release, to the Nova Scotia Department of Health & Wellness by the Canada Revenue Agency, of
information from my income tax returns and if applicable, other required taxpayer information about me/us. This information will be
relevant to and used solely for the purpose of determining eligibility and enrollment in the Nova Scotia Family Pharmacare Program,
and will not be disclosed to any person without my/our approval. This authorization is valid for two taxation years prior to my signing
the application and each subsequent consecutive taxation year for which assistance is requested by me or on my behalf. I
understand that, if I wish to withdraw this authorization, I may do so at any time by writing to the Nova Scotia Family Pharmacare
Program.
Signature of Applicant
Date
Signature of Spouse (if applicable)
Date
DECLARATION
I declare that all the information I have provided in this form is complete and I understand that a false statement constitutes
fraud and may result in termination of benefit coverage.
Signature of Applicant
Date
Signature of Spouse (if applicable)
Date
Form 599 April 2019
How do we define “Family Applicant”?
A family applicant must be an adult (refer to definition below) and will be the person to whom all correspondence
relating to the program will be sent.
How do we define “Adult”?
An adult is a person 18 years of age and over.
How do we define “Family”?
A family is:
• a single adult
• an adult and spouse (refer to definition below)
• an adult and all dependant children (refer to definition below)
• an adult, spouse, and all dependant children
Note: Include all family members on the registration form, even if some family members have drug coverage through
other programs. All family members are included in the copayment and deductible calculations.
How do we define “Spouse”?
A spouse is a person who is married to you or with whom you are living in a marriage-like relationship. A spouse may
be of the same gender.
How do we define “Dependant Child”?
A dependant child is:
• a child or a legal ward of you or your spouse
• supported by you or your spouse
• younger than 18 years of age
• not married and not living in a marriage-like relationship
A dependant child can only be registered with one family at any given time.
Who is eligible?
You may register for this Program if you:
• are an eligible Nova Scotia resident; and
• have a valid Nova Scotia Health Card
• are under age 65, or live with a spouse or dependent under age 65
You are not eligible if you are receiving drug coverage through:
• the Nova Scotia Seniors’ Pharmacare Program;
• the Nova Scotia Diabetes Assistance Program;
• the under 65-Long Term Care Pharmacare Plan; or
• any Department of Community Services Pharmacare Benefits.
Note: Any portion of a prescription cost, for any family member that is eligible for coverage under another drug
program, will not be considered for coverage under the Nova Scotia Family Pharmacare Program.
What if I am single, 18 years of age or over and still living with my family?
If you are 18 years of age or over, you must complete your own registration form. If you live with your parents and do
not have a spouse or dependants, you are a family of one for our purposes. Do not include your parents’ names or
their incomes on your registration form.
If you have any questions or require help to fill out the application form, please call (902) 496-5667, or 1 (877) 330-
0323 (if you live outside the metro Halifax area), or visit our website: www.nspharmacare.ca
Mail your completed form to: or fax to: (902) 468-9402
Nova Scotia Family Pharmacare Program
Nova Scotia Pharmacare Programs
PO Box 500
Halifax, Nova Scotia
B3J 2S1
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Family Pharmacare Registration Form

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Completed 28 July 2020

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