Patient Connect NB - Online Updates to Registrations

By providing the information required below, and updating my file, I recognize and agree that the Department of Health collects, uses, and may disclose this information for the purpose of trying to find a primary health care provider for myself and so that I can participate in this program.

By clicking the checkbox you confirm that you have read, understand and agree with the above statements.

Required fields are indicated with an " * " and bordered in red.

Name as it appears on your Medicare card:

Medicare Number:

Date of birth:

Please select the update or change required

I have found a provider and can be removed from the list

I need to update my Medicare Number

New Medicare Number:

I need to update my phone number

New phone number:

Confirm phone number:

I need to update my address

New address

Postal Code:

Street Number:

Street Name:

Street Type:

Apartment/unit number:

City, Town or Village:

Province:

* Enter the code exactly as it appears:

ELECTRONIC SIGNATURE

TYPING IN YOUR NAME AND ELECTRONICALLY SENDING THIS FORM CONSTITUTES YOUR ELECTRONIC SIGNATURE.

* Signature

* Date (yyyy/mm/dd)