Discount Provider

Welcome!

Please enter all the information on the form. Ensure that you select [New] or [Renewal] at the top of the form to
on relevant to you and/or your family in this
let us know your requirements and we will contact you via e-mail or by
telephone within 24 hours after you submit your information for
processing.

Thank you in advance and we look forward to the opportunity to serve you.

Type of Application      New     Renewal
First Name:
Middle Initial:
Surname:
Address :
Tel :
Home : Work :
Date of Birth :
                              Sex:          Male     Female
E-Mail:
Employer's Name:   
Employer's Address:   
Are you covered under
a Health Plan?		 Yes   No 
Insurance Co.
Regular Membership
Individual 
Individual & Dependant 
Family 
$199
$299
$399
RBTT Customers
RCS & Plan 55
Individual 
Individual & Dependant     
Family
$125
$205
$275
Regular RBTT Customers
Individual 
Individual & Dependant     
Family
$145
$225
$295
Senior Citizens
(55 years and over)
Individual 
Individual & Dependant     
Family
$149
$229
$299
Proof of age
I.D. No.
D.P. No.
Passport No.
Please List dependents. Only persons listed here will be eligible for  Medicard benefits.
Dependents are your Spouse (including Common-law) and unmarried
children under 23 years of age.
Name Date of Birth   Relationship  
     
     
     
     
     
Medicard Limited must be notified of any new dependents. An additional Card will be
issued in the name of the child FREE of charge.

NOTE: Only one card is issued for an Individual Application. Two cards are issued for the Individual and One Dependent, and two cards are issued for the Family Application.

For Family Plans, should you require any additional cards there is a fee of $20.00 each.
Lost / Stolen cards cost $20.00 to replace.
How many additional cards would you like?:
Please list the additional card holder(s)
How would you like
to receive your card
after payment?