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Family Member Information
Legal Status Information
Legal first name as it appears on the Manitoba health card
*
*
Legal last name as it appears on the Manitoba health card
*
*
Date of birth
*
*
Relationship to the primary applicant
*
Sibling
Dependant
Is the family member registered with Manitoba health?
*
Yes
No
Manitoba health registration number (six-digit alphanumeric)
*
Personal Health Identification Number (PHIN - nine digits)
*
Mother's first name as it appears on the Manitoba health card
*
Mother's last name as it appears on the Manitoba health card
*
Mother's date of birth
*
Is the family member currently registered in another province/territory?
Yes
No
Specify another province/territory
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Date of arrival in Manitoba
*
