Application for Interim Federal Health Coverage Extension (Canada)
This form is for an extension of Interim Federal Health Coverage in Canada. The form provided here is simply a sample of what the actual Form 5568E looks like.
Citizenship and Immigration Canada
IMMIGRATION
Canada
Application for IFH Coverage
Extension
Table of Contents
Overview
Who is eligible
When to apply
How to apply
Where to send your application
If you move
How to complete the forms
What happens next
Appendices
A - List of CIC offices
B - Photo Specifications
Forms
Application for IFH Coverage - Extension (IMM 5564)
Use of a Representative (IMM 5476)
This application is made available free by Citizenship and Immigration Canada and is not to be sold to applicants.
IMM 5568E (06-2009)
Contact Information
Web site
For more information on the programs offered by Citizenship and Immigration Canada, visit our Web site at www.cic.gc.ca. For some types of applications you can inform us of a change of address and find out what is happening with your application through on-line services on the Web site.
Within Canada
If you are in Canada, you can also phone our Call Centre. An automated telephone service is available seven days a week, 24 hours a day and is easy to use if you have a touch-tone phone. You can listen to pre-recorded information on many programs, order application forms, and for some types of applications the automated service can even update you on the status of your case.
When you call, have a pen and paper ready to record the information you need. Listen carefully to the instructions and press the number for the selection you want. At any time during your call, you may press * (the star key) to repeat a message, 9 to return to the main menu, 0 to speak to an agent, or 8 to end your call. If you have a rotary phone, wait for an agent to answer you. If you need to speak to an agent, you must call Monday to Friday between 8 a.m. and 4 p.m. local time.
From anywhere in Canada, call 1-888-242-2100 (toll-free)
Using a text telephone?
Call our TTY service from Monday to Friday between 8 a.m. and 4 p.m. local time at: 1-888-576-8502 (toll-free).
Outside Canada
If you are outside Canada, you can contact a Canadian embassy, high commission or consulate. Consult our Web site for addresses, phone numbers and Web site addresses of our visa offices.
This is not a legal document. For legal information, refer to the Immigration and Refugee Protection Act and Regulations or the Citizenship Act and Regulations, as applicable.
This publication is available in alternative formats upon request.
Overview
The Application for IFHP coverage - Extension kit is for persons who are eligible for the Interim Federal Health Program (IFHP) and who want to apply for an extension of their healthcare coverage under this program.
It cannot be used to request a replacement of the original document granting IFHP eligibility to a candidate, such as the Acknowledgement of Convention Refugee Claim, the Determination of Eligibility Pursuant to Paragraph A100(1) or the Interim Federal Health Certificate, if that document is stolen, lost or destroyed.
Read the following instructions carefully. Forms that are incomplete or illegible, or that are not accompanied by the required documents may take longer to process or may be returned.
If you have any questions after reading this kit, contact the Call Centre. Information on how to contact us is provided on the inside cover of this guide.
Who is eligible
Only persons belonging to one of the following categories who are unable to pay for essential and emergency healthcare and who are not covered by a public or private health insurance plan (see Note) may apply for an extension of their IFHP eligibility period.
• Refugee protection claimants and their in-Canada dependent children, other than those who
· are not eligible to have a claim determined by the Refugee Protection Division of the Immigration and Refugee Board;
· have abandoned or withdrawn their claim for refugee protection; or
· were determined to have no credible basis for a claim to refugee protection.
• Applicants for a Pre-Removal Risk Assessment (PRRA) upon application and during the in-Canada process.
• Refugee protection claimants who received negative decisions from the Refugee Protection Division of the Immigration and Refugee Board while legally in Canada, unless they were granted the right to apply for permanent residence.
• Refugee protection claimants (determined in Canada) and their in-Canada dependent children for the duration of the qualifying waiting period imposed by the healthcare plan of their province of residence (maximum of three months after determination).
• All refugees and persons in similar circumstances selected abroad in the following classes:
· Convention Refugees Abroad Class;
· Source Country Class; or
· Country of Asylum Class.
• Persons being detained by Citizenship and Immigration Canada.
Note: With the exception of persons being detained by Citizenship and Immigration Canada, applicants who are sponsored privately or have been accepted into the Resettlement Assistance Program (RAP) may be eligible, once they have access to provincial health insurance, for limited coverage under the IFHP for the duration of the private sponsorship or the RAP.
When to apply
Citizenship and Immigration Canada (CIC) centres process applications for IFHP eligibility extensions as quickly as possible, depending on the condition of the application and the services required. If you meet the eligibility requirements and your situation requires that you continue to have access to the IFHP, you should submit an application for an extension four weeks before the expiration date of your most recent eligibility period for this program, at the earliest.
How to apply
Each application must include the principal claimant and, if applicable, his or her dependants whose IFHP eligibility periods need to be extended. Dependants include the principal claimant's wife, husband or common-law spouse, and their dependent children.
Be sure to sign your application form and attach all the support documentation required. Your application may be returned if any information or documents are missing.
Your application must include
• The Application for IFHP Coverage - Extension (IMM 5564) form.
• The Use of a Representative (IMM 5476) form, if you are paying a representative to help you complete your application or if you authorize us to discuss your application with someone other than yourself.
• A recent photograph of each person whose name appears on the application. Photographs must have been taken in the six months preceding your request and must meet the attached specifications (see Appendix B). The name of the person appearing in the photograph must be written on the back of the photograph.
• A clear and legible photocopy of the most recent of the following documents that CIC issued to you and to your dependants:
· Acknowledgement of Convention Refugee Claim
· Determination of eligibility pursuant to paragraph A100(1)
· Interim Federal Health Certificate
· any other document Canadian immigration authorities have issued to you and, if applicable, your family members.
Where to send your application
Place your forms and all support documentation in an envelope and mail them to the nearest Citizenship and Immigration Centre listed at Appendix A. Be sure to use sufficient postage on the envelope.
If you move
If you change your address after you submit your application, please notify us immediately
• by e-mail, using the CIC on-line service (consult our Web site and follow the instructions on how to complete and send the electronic change of address form); or
• by telephone, by calling the Call Centre.
How to complete the forms
Instructions and clarifications are provided as required. If you need assistance, contact the CIC Call Centre. Print clearly.
Application for IFHP Coverage - Extension (IMM 5564)
Section A
Client identification number: You will find this number on the official document issued to you by the CIC office, the Case Processing Centre, or the visa office where you filed your claim. Your client identification number consists of four numbers, a hyphen (-) and four more numbers. (Example: 0000- 0000).
Section B
If the IFHP eligibility period for other members of your family is going to expire soon, please include their names on your application form, indicating each person's given and family names, client identification number (see Section A above), and relationship to you. Do not include the names of family members for whom you are not requesting an extension of their IFHP eligibility period.
Section C
Complete Section C only if you filed a refugee protection claim in Canada.
Section D
If you have included one or more family members in Section B and if their addresses in Canada are different from your own, write their addresses here in the order in which they appear (I, II, III, IV or V) in Section B.
Section E
Please be sure to sign your application.
Use of a Representative (IMM 5476)
Complete this form if you are appointing a representative.
If you have dependent children aged 18 years or older, they are required to complete their own copy of this form if a representative is also conducting business on their behalf. A representative is someone who has your permission to conduct business on your behalf with Citizenship and Immigration Canada. When you appoint a representative, you also authorize CIC to share information from your case file to this person. You are not obliged to hire a representative. We treat everyone equally, whether they use the services of a representative or not. If you choose to hire a representative, your application will not be given special attention nor can you expect faster processing or a more favourable outcome. The representative you appoint is authorized to represent you only on matters related to the application you submit with this form. You can appoint only one representative for each application you submit.
There are two types of immigration representatives:
Unpaid representatives
• friends and family members who do not charge a fee for their advice and services
• organizations that do not charge a fee for providing immigration advice or assistance (such as a non-governmental or religious organization)
• consultants, lawyers and Québec notaries who do not, and will not, charge a fee to represent you
Paid representatives
If you want us to conduct business with a representative who is, or will be charging a fee to represent you, he or she must be authorized. Authorized representatives are:
• immigration consultants who are members in good standing of the Canadian Society of Immigration Consultants (CSIC)
• lawyers who are members in good standing of a Canadian provincial or territorial law society and students-at-law under their supervision
• notaries who are members in good standing of the Chambre des notaires du Québec and students-at-law under their supervision
If you appoint a paid representative who is not a member of one of these designated bodies, your application will be returned. For more information on using a representative, visit our Web site.
Section B.
5. Your representative's full name
If your representative is a member of CSIC, a law society or the Chambre des notaires du Québec, print his or her name as it appears on the organization's membership list.
8. Your representative's declaration
Your representative must sign to accept responsibility for conducting business on behalf of the sponsoring group.
Section D.
10. Your declaration
By signing, you authorize us to complete your request for yourself and your dependent children under 18 years of age. If your spouse or common-law partner is included in this request, he or she must sign in the box provided.
Release of information to other individuals
To authorize CIC to release information from your case file to someone who is not a member of your sponsoring group and is not a representative, you will need to complete form Authority to Release Personal Information to a Designated Individual (IMM 5475) which is available on our Web site at www.cic.gc.ca/ english/applications/release-info.
The person you designate will be able to obtain information on your file, such as the status of your application. However, he or she will not be able to conduct business on your behalf with CIC.
You must notify us if your representative's contact information changes or if you cancel the appointment of a representative.
What happens next
If your application is complete, the appropriate CIC centre will evaluate your eligibility and contact you if you need to provide more information or documents, or if you have to appear for an interview. If you meet all the eligibility requirements for the program, the CIC centre will issue an Interim Federal Health Certificate of Eligibility to you. Your eligibility period will be determined based on your particular situation and will be no more than 12 months. Attached to this certificate will be a list of services covered under the program, as well as those that are not covered.
If your application for an extension is denied, the CIC centre will notify you in writing.
Appendix A
Citizenship and Immigration Centres
ATLANTIC
Charlottetown
191 University Ave.
Charlottetown, PE C1A 4L2
Fredericton
495 Prospect Avenue
Fredericton, NB E3B 9M4
Halifax
1741 Brunswick Street, Suite B110
Halifax, NS B3J 3X8
Moncton
860 Main Street, 6th Floor, Suite 602
Moncton, NB E1C 1G2
Saint John
189 Prince William Street
Saint John, NB E2L 2B9
St. John's
North Atlantic Building, 2nd floor
31 Pippy Place
P.O. Box 13667, Station "A"
St. John's, NL A1B 4G1
QUEBEC
Gatineau
259 St-Joseph Blvd, Suite 109
Gatineau, QC J8Y 6T1
Montréal
1010 St-Antoine St. West, 2nd floor
Montréal, QC H3C 1B2
Québec
Complexe Lebourgneuf
825 Lebourgneuf Blvd, Suite 110
Québec, QC G2J 0B9
Sherbrooke
76 Place de la Cité
Sherbrooke, QC J1H 4G8
Trois-Rivières
55 des Forges Blvd., Room 012
Trois-Rivières, QC G9A 6A8
ONTARIO
Greater Toronto Area,
including Etobicoke, Mississauga
and Scarborough
25 St. Clair Avenue East, Suite 200
Toronto, ON M4T 1M2
Outside the Greater Toronto Area
Send your application to the closest
CIC as follows:
Barrie
48 Owen Street, Suite 312
Barrie, ON L4M 3H1
Hamilton
55 Bay Street North
Hamilton, ON L8R 3P7
Kitchener
Waterloo/Wellington CIC
29 Duke Street. East
Kitchener, ON N2H 1A2
London
417 Exeter Road
London, ON N6E 2Z3
Niagara Falls
6080 McLeod Road, Unit 12
Niagara Falls, ON L2G 7T4
Oshawa
78 Richmond Street West, 2nd floor
Oshawa, ON L1G 1E1
Ottawa
(includes Kingston)
200 Catherine Street, Suite 101
Ottawa, ON K2P 2K9
Sault Ste. Marie
22 Bay Street
Sault Ste. Marie, ON P6A 5S2
Sudbury
19 Lisgar Street, Room 305
Sudbury, ON P3E 3L4
Thunder Bay
221 Archibald St. North, Suite 108
Thunder Bay, ON P7C 3Y3
Windsor
1250 Walker Road
Windsor, ON N8Y 4T4
PRAIRIES/NORTHERN TERRITORIES
Calgary
Harry Hays Building, Room 170
220 4th Avenue S.E.
Calgary, AB T2G 4X3
Edmonton
(including residents of Northwest
Territories)
Suite 240, Canada Place
9700 Jasper Avenue
Edmonton, AB T5J 4C3
Regina
1783 Hamilton Street, Room 220
Regina, SK S4P 2B6
Saskatoon
660 - 410 22nd Street East
Saskatoon, SK S7K 5T6
Winnipeg
(including residents of Nunavut)
Johnston Terminal, Room 400
25 Forks Market Road
Winnipeg, MB R3C 0S9
BRITISH COLUMBIA/YUKON
Kelowna
202- 1635 Abbott Street
Kelowna, BC V1Y 1A9
Nanaimo
60 Front Street, Room 201E
Nanaimo, BC V9R 5H7
Prince George
250 - 177 Victoria Street
Prince George, BC V2L 5R8
Vancouver
1148 Hornby Street
Vancouver, BC V6Z 2C3
Victoria
816 Government Street, Room 377
Victoria, BC V8W 1W9
Whitehorse
300 Main Street, Suite 215
Whitehorse, YT Y1A 2B5
Appendix B
Photo Specifications
Notes to the applicant
TAKE THIS WITH YOU TO THE PHOTOGRAPHER
• Immigration photographs are not the same as passport photographs.
Notes to the photographer
The photographs must:
• show a full front view of the person's head and shoulders showing full face centred in the middle of the photograph;
• have a plain white background;
• be identical (black and white or colour) produced from the same untouched negative, or exposed simultaneously by a split-image or multi-lens camera;
The photographs must:
• measure between 25 mm and 35 mm (1" and 1 3/8") from chin to crown
• have a 35 mm x 45 mm (1 3/8" x 1 3/4") finished size
45 mm (1 3/4")
35 mm (1 3/8")
Max. 35 mm (1 3/8")
Min. 25 mm (1")