Government of Ontario: Ministry of Health and Long-Term Care

Notification of Change of Information for
Trillium Drug Program

Print clearly. Make sure to provide your File / Registration N°.


–   –   –  

You are obligated to immediately report in writing changes that will impact your program eligibility such as change of household membership, private insurance, CCRA consent and annual net household/recipient income.
Complete and return this form to the Trillium Drug Program to report any missing information or changes to your household. Attach supporting documents where applicable.

Indicate ( √ ) what change(s) you want to make on the check boxes below.


Address

Address    





  

Home telephone number (
Work telephone number (    

Private Insurance Information

Private Insurance Information    

Note:




 


If there is more than one insurance plan, write the information on a separate sheet of paper. Provide the same information as above.

Household Member Information

Household Member Information    

  1.   
      
    Sex    

      




  2.   
      
    Sex    

      



* Includes a letter of explanation signed and dated by the household member who wishes to be removed.

If there are more than two additional household members, write their information on a separate sheet of paper. Provide the same information as above. Each additional household member, 16 years of age and older, must sign sections 1 and 2 of the Declaration page on the reverse.

  1. Declaration

    By signing this form, I confirm that:

    • I am providing information on this form for the purpose of updating household registration information under the Trillium Drug Program,
    • I understand that I can request to terminate my registration at anytime,
    • the information provided in this Notification of Change form is true, correct and complete to the best of my knowledge,
    • I understand that I must immediately notify the Trillium Drug Program in writing of any changes that will impact eligibility including Household Members, Private Insurance Coverage, or any changes to the household or recipient annual Net Income amount,
    • the Ministry of Health and Long-Term Care or its agents may collect any information from any source to verify the information in this form,
    • the address given on the reverse will be the official address to be used by the Ministry of Health and Long-Term Care for all household members listed on this form.






  2. Consent for Canada Revenue Agency to Release my Income Information to the Ministry

    I authorize the Canada Customs and Revenue Agency to release to the Ministry of Health and Long-Term Care information from my income tax returns and other required taxpayer information whether supplied by me or a third party. The information will be relevant to, and used solely for the purpose of determining and verifying eligibility, including determining appropriate deductible amounts, and for the administration of the Trillium Drug Program of the Ontario Drug Benefit Program under the Ontario Drug Benefit Act, and will not be disclosed to any other person or organization without my approval, except as required or permitted by law. This authorization is valid for the most recently available of the two taxation years prior to signing this consent and each subsequent consecutive taxation year for which assistance under the Ontario Drug Benefit Act may be requested and determined. I understand that, if I wish to withdraw this consent, I may do so at any time by writing to the Trillium Drug Program, PO Box 337, Station D, Etobicoke ON  M9A 4X3.


  1.     
    If the signature is not that of the household member, print the signatory’s information below, and
    attach supporting documents, as appropriate

      

    Identity of signatory * (see below)
           


  2.     
    If the signature is not that of the household member, print the signatory’s information below, and
    attach supporting documents, as appropriate

      

    Identity of signatory * (see below)
           

*Categories for signatory identification:

  1. Person’s Guardian of property
  2. Person’s Guardian of the person
  3. Person’s Attorney under continuing power of attorney
  4. Person’s Attorney under power of attorney for personal care
  5. Substitute Decision Maker