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Adobe PDF Adobe PDF document  Health Card Medical Exemption RequestThe file you are about to download will ONLY work properly if opened with an Adobe Reader 10 or later client. Please do not open this file in a browser.Paper Copy Available
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Form Classification
Classification / Identification:
 Form Number:014-3164-84Edition date: 2015/04 
 Title:Health Card Medical Exemption Request
 Ministry:Health and Long-Term Care  
 Branch/ABC:Claim Services Branch  
 Program:Claims Services  
 Purpose of Form:Form completed to request exemption, i.e., no photo to appear on photo health card  

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