APPLICATION FOR
NEWFOUNDLAND AND LABRADORHEALTH CARE COVERAGEHealth and Community Services••••Medical Care PlanDO NOT ENTER TEXT ON THIS FORM WHEN IT IS OPEN IN A WEB BROWSERSAVE IT TO YOUR COMPUTER FIRST AND OPEN IT FROM THERE
PLEASE READ THE FOLLOWING INFORMATION BEFORE COMPLETING THE APPLICATION ON THE REVERSE
If you are applying for coverage with the Newfoundland and Labrador Medical Care Plan (MCP) you must complete this form.
If you are applying for coverage for a newborn or adopted child please complete the Newborn/Adopted Child Registration form.
All forms are available on our website at www.gov.nl.ca/mcp and by calling MCP at one of the numbers listed at the bottom of this page.
There are no charges or fees for MCP cards or registration.

DOCUMENTS YOU MUSTSUBMIT WITH THIS APPLICATION (Submit clear copies only. Do not submit original documents unlessrequested.) Canadian Citizens moving to Newfoundland and Labrador must provide a clear copy of one of the following documents:• Valid Canadian Passport or Government issued Proof of Canadian Citizenship.
• Birth Certificate issued by a Canadian province or territory. (Baptismal/Dedication Certificates are not acceptable.)
Non-Canadians moving to Newfoundland and Labrador must provide clear copies of the following documents:• Valid Immigration document from IRCC. (Example: Work Permit; Study Permit; Visitor Permit).
• Valid Passport. (Copy of identification section only.)• For International Students: Letter (issued since your arrival in Newfoundland and Labrador and dated within 30 days of thesubmission of this form) from your Educational Institution verifying full-time enrolment.
• For International Workers: Letter (issued since your arrival in Newfoundland and Labrador and dated within 30 days of the submissionof this form) from your Employer verifying full-time employment.
OR• Permanent Resident Card. (A copy of both the front and back of the card is required.)
MCP may request that additional documentation or originals of the items listed above be presented if deemed necessary.

INELIGIBLE APPLICANTS
The following are not eligible for MCP coverage:• Tourists, transients and visitors.
• Members of the Canadian Forces or NATO Forces.
• Inmates of Federal prisons.
• Persons moving to Newfoundland and Labrador for a period of less than one year unless otherwise allowed under MCP criteria.
WAITING PERIOD
If you are moving permanently to Newfoundland and Labrador from another Canadian province or territory you will be coveredby your previous Plan for the remainder of the month you arrive in Newfoundland and Labrador plus the following two months. In
order to allow sufficient time for administration of the change in coverage from your previous Plan to MCP you should applyfor MCP coverage immediately upon arrival in Newfoundland and Labrador.
HEALTH CARECARDS
If they are eligible for coverage each person listed on the application will receive an MCP identity number and card. Keep the card with you
at all times and present it each time you receive medical services. Contact MCP immediately if your card becomes lost,stolen, damaged or destroyed. Card replacement forms are available on-line and at doctors’ offices and hospitals throughout the province.
INTENT FOR ORGAN/TISSUE DONATIONYour intent to donate is supported by the Human Tissue Act. You can indicate your intent by signing in the space provided on the reverse.
SIGNATURE
This form must be signed by the applicant in Section 6. (If the applicant is under age 16 a parent or legal guardian must sign instead.)
IT IS IMPORTANT THAT YOU NOTIFYMCP OF CHANGES TO YOUR NAME, ADDRESS OR RESIDENCY STATUS
MCP 45 Major's Path
PO Box 8700, St. John’s, NL A1B 4J6
Telephone: 709-758-1600 Toll Free: 1-866-449-4459 or 1-800-563-1557 Facsimile: 709-758-1694
www.gov.nl.ca/mcp

Revised: August 15, 2023

APPLICATION FOR
NEWFOUNDLAND AND LABRADORHEALTH CARE COVERAGE

Health and Community Services

Medical Care Plan

DO NOT ENTER TEXT ON THIS FORM WHEN IT IS OPEN IN A WEB BROWSERSAVE IT TO YOUR COMPUTER FIRST AND OPEN IT FROM THERE
SECTION 1

LIST BELOW YOUR NAME AND THE NAMES OF ANY OF YOUR DEPENDANTS REGISTERING FOR HEALTH CARE COVERAGE(Attach a separate sheet if more space is required)
All Given Names (in full)

SurnameSECTION 2First Name

Surname at BirthMiddle Name

Sex/Gender
M/F /X

City / Town

Phone

DD

Previous Province Health
Insurance No.(if applicable)

Province Postal CodeNLCell Number

E-mailMARITAL STATUS
law-is not already 
registered with MCP they must (If your spouse-legal or common also register at this time)Single
SECTION 4MM

HOME MAILING ADDRESSHome Mailing Address

SECTION 3

Birth DateYYYYMarriedCommon Law

Separated

Divorced

WidowedANSWER ALL OF THE FOLLOWING QUESTIONS (Please print.
 See reverse
for required documentation.)

1.

Yes
No
Have you or your dependents been registered with MCP before?
If YES please list on a separate sheet the previous MCP numbers (if available) of all persons to be registered.

2.

When did you and/or your dependents move to Newfoundland & Labrador? (YYYY/MM/DD)

3.

Are you moving to Newfoundland & Labrador from another part of Canada?

4.

Are you moving to Newfoundland & Labrador from outside Canada?

5.

Reason for moving to Newfoundland & Labrador.

6.

How long do you intend to reside in Newfoundland & Labrador?

7.

Have all of your dependents moved with you to Newfoundland & Labrador?

8.

Are any of the applicants listed on this form a member of:Work

Yes (Province/Territory)No

Yes (Country)
StudyNo

OtherYes

Canadian Forces

No (explain)
NATO Forces

Part-time Reserve

Name(s) of applicants
SECTION 5

INTENT FOR ORGAN/TISSUE DONATION(If anyone named on this form wishes to become an organ/tissue donor, please sign in one of the spaces below. Your intent todonate is supported by the Human Tissue Act. If signing below, please also print your name)Electronic or Written Signatureand Printed Name
Electronic or Written Signatureand Printed NameSECTION 6

Electronic or Written Signatureand Printed Name
Electronic or Written Signatureand Printed NameDECLARATION (This application will not be processed if the section below is not completed. See instructions on reverse side ofthis form.)

IT IS AN OFFENCE TO GIVE FALSE INFORMATION FOR THE PURPOSE OF OBTAINING COVERAGE UNDER THE NEWFOUNDLAND & LABRADOR MEDICAL CARE PLAN

I
hereby declare that I am the person named on the form, the information given is correct and the person(s) listed on
this form are residents of Newfoundland and Labrador. In lieu of a written signature my typed name on the form shall be considered my electronic signature.
Electronic or Written Signature of Applicant:

Date:

PRIVACY NOTICE: The Newfoundland and Labrador Medical Care Plan (MCP) collects personal health information under the authority of the Medical Care and Hospital Insurance Act. Personal health information is collected, used, disclosed
and safeguarded in accordance with the Personal Health Information Act (PHIA). If you have any questions about the collection or use of this information please contact our office.

MCP 45 Major's Path
PO Box 8700, St. John’s, NL A1B 4J6
Telephone: 709-758-1600 Toll Free: 1-866-449-4459 or 1-800-563-1557 Facsimile: 709-758-1694
www.gov.nl.ca/mcp