Application Forms
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- Access to Information and Protection of Privacy (Department of Justice)
- Address Change Form (Health Care Coverage)
- Adoption Registry - Application for Information
- Application for Birth/Marriage/Death Certificate
- Application for Change of Name
- Application for Métis Health Benefits
- Change of Aboriginal Status (Health Care Coverage)
- Extended Health Benefits (EHB)
- Health Promotion Fund
- Information Request (Children and Family Services)
- Name Change Form (Health Care Coverage)
- Non Insured Health Benefits (Health Canada)
- Professional Development Initiative (PDI)
- Request for Health Care Coverage
- Small Community Homelessness Fund
- Supplementary Health Benefits
- Temporary Absence Form (Health Care Coverage)
- Other
| Note: | Bursary forms for students pursuing careers in health and social services are available online. For more information on these bursaries and other forms of student support, see section on HSS Careers. |
Address Change Form (Health Care Coverage)
- English (PDF - 112.53 KB)
Adoption Registry - Application for Information
- English (PDF - 42.21 KB)
Application for Birth/Marriage/Death Certificate
- English (PDF - 174.55 KB)
Please note that we now accept Visa or MasterCard for payment. When you fax us your application, you can now call us with your credit card information. Also, please note that the "date of registration" and "registration number" asked for on the application is not required as this is for office use only.
Please note that for the Death Certificate, we only provide the paper certificate.
Birth, Death and Marriage Certificates are printed every Thursday.
Application for Change of Name
Fill out the application for change of name package if you want to legally change your name. You do not need to apply for a legal name change after you are married or divorced.
- Application Forms
- Application for Change of Name package (PDF - 225.79 KB)
-
Application for Duplication Change of Name Certificate (PDF - 67.08 KB)
- Statutory Declaration
- Breakdown of Spousal Relationship (PDF - 96.56 KB)
- Use of Common-Law Spouse’s Last Name (PDF - 89.40 KB)
Application for Métis Health Benefits
-
English (PDF - 111.70 KB)
Note: Paper size is 8.5" by 14".3
Change of Aboriginal Status (Health Care Coverage)
- English (PDF - 122.71 KB)
Extended Health Benefits (EHB)
- EHB Additional Assistance Claim (PDF - 94.86 KB)
- EHB Application (English/French) (PDF - 92 KB)
- EHB Expense Claim (PDF - 79.29 KB)
- EHB Prior Approval Form for Equipment/Appliance for Program Clients (PDF - 54.96 KB)
- EHB Request for Exception Drug Coverage (PDF - 62.29 KB)
- EHB Seniors Program Application (PDF - 82.2 KB)
EHB payments are processed within 20 working days of the receipt date pending all required documentation.
- English (PDF - 276.40 KB)
Information Request (Children and Family Services)
- English (PDF - 216.80 KB)
Name Change Form (Health Care Coverage)
Use this form if your name has changed, and you want your health care card to show your new name.
- English (PDF - 122.24 KB)
Non Insured Health Benefits (Health Canada)
- NIHB Client Reimbursement Request Form
- NIHB General Medical Supplies and Equipment Prior Approval Form
Professional Development Initiative (PDI)
- English (PDF - 60.15 KB)
The Professional Development Initiative (PDI) is intended to provide specific Health and Social Services Front Line Professionals and Managers, working within the NWT Health and Social Services System, with increased opportunities for professional development, education and training.
Request for Health Care Coverage
- English (PDF - 128.05 KB)
Use the form if you are new to the NWT and require an NWT health care card. Do not use this form to renew your current health care card - instead, contact the Health Services Administration Unit at 1-800-661-0830 for information on how to renew your health care card.
Small Community Homelessness Fund
- Application Form (PDF - 96.97 KB)
- Criteria and Guidelines (PDF - 80.58 KB)
- Application for Supplementary Health Benefits (PDF - 91.13 KB)
- Appeal to the Appeals Committee (PDF - 30.38 KB)
Temporary Absence Form (Health Care Coverage)
- English (PDF - 72.14 KB)
The Temporary Absence Form is to be completed if you will be out of the NWT for more than 3 months (90 days) for medical, work or school.
- Direct Deposit Form (Financial Management Board Secretariat)
On July 2, 2002 the Government of the Northwest Territories (GNWT) launched the Direct Deposit service to have payments deposited to Canadian bank accounts of businesses, government entities, individuals, organizations and students. Students who receive financial assistance from the HSS bursaries; and individuals who receive payment reimbursements from Extended Health Benefits program are eligible for the Direct Deposit service.
Through Direct Deposit, payees will receive money faster and with greater efficiency. This service is provided free of charge.