MSI Renewal Form
Name
First Name
Middle Name
Last Name
Please type your health card number in the box provided
Date of birth
-
Month
-
Day
Year
Date
Daytime Phone Number
Please enter a valid phone number.
Other Phone Number
Please enter a valid phone number.
Mailing Address
Street Address
Home Address (if different)
City
Province
Postal Code
Has your address recently changed?
Yes
No
If so, is this a complete family move?
Yes
No
I certify that I am a resident of Nova Scotia. A resident is a person who makes his/her home and is ordinarily present (physically present for at least 183 days calendar days per year) in Nova Scotia. I authorize any health service provider paid by Medical Services Insurance (MSI) to release any information requested by MSI for claims payment and audit.
Date Signed:
-
Month
-
Day
Year
Date
Your organ and tissue donation decision
It is your choice. You can indicate a donation decision below or choose not to register one. You can change a previous decision at any time. If you are 19 or older and eligible, you will be seen as agreeing to be an organ and tissue donor after your death, unless you register a decision to opt out of donation. This will be confirmed with your family at the time of your death. Learn more about who is eligible at www.novascotia.ca/organtissuedonation or by calling MSI at 1-800-563-8880 or 902-496-7008 in HRM.
Do you want to register a donation decision now?
Yes, I want to be a donor and donate all organs and tissues (donor 1)
Yes, I want to be a donor and ONLY donate the following organs and tissues (donor 2)
*If you chose Donor 2, please choose the organs. If Donor 1 or Opt Out, leave blank.
Lungs
Heart
Liver
Kidneys
Pancreas
Small bowel
Skin
Veins
Eyes
Bone and related structures
Heart valves/Pericardium
No, I don’t want to be a donor (opt out)
Talk about it
Talk with your family, friends and those closest to you to make sure they know your donation decision.
Find out more
Learn more about your organ and tissue donation choices, and recent changes to Nova Scotia’s organ and tissue donation legislation at www.novascotia.ca/organtissuedonation. Learn about organ and tissue donation atwww.nshealth.ca/legacy-life or by calling 1-877-841-3929 for organ donation and 1-800-314-6515 for tissue donation.
Submit
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