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Form 3164-84: Ontario Health Card Medical Exemption

Patients use this request when a medical condition prevents them from going to a ServiceOntario centre for a health card photo or signature, or from having the photo or signature captured there. The patient asks for a photo exemption, a signature exemption or both, and a physician or nurse practitioner confirms the medical reason. The patient then takes the completed form to ServiceOntario.

Who completes it

The physician or nurse practitioner completes Part B: whether the condition is permanent or subject to change, their college registration (CPSO, or CNO as a registered nurse in the extended class), college number, printed or stamped name and address, and signature. The card holder or legal representative completes and signs Part A.

Submitting and payment

How to submit it
The patient brings the completed form to a ServiceOntario centre with a completed health card registration, renewal or re-registration form, one original document from each of three categories on the coverage document list, and any power of attorney.

Good to know

  • The provider marks the condition permanent or subject to change; an exemption based on a condition subject to change requires a health reassessment in 5 years.
  • The form also suits temporary situations: its instructions give the example of someone unable to sign their name while recovering from an accident or surgery.
  • A legal representative completing Part A on the card holder's behalf must provide a document proving that status, such as a power of attorney.
  • The posted edition, 3164-84 (2014/02), is a single bilingual English and French form with fillable fields for the patient and provider details.

Get the official form

Download the current version from the source each time; forms change without notice.

Health Card Medical Exemption Request

Demande d'exemption médicale - Carte Santé

Official pagePDF

Fill it with Vero

Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.

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Frequently asked questions

Who can sign the Ontario health card medical exemption?

Part B must be completed by the card holder's physician or nurse practitioner. The provider indicates registration with the College of Physicians and Surgeons of Ontario or with the College of Nurses of Ontario as a registered nurse in the extended class, and adds their college number, printed or stamped name and address, and signature.

Can a patient get an Ontario health card without a photo?

Yes, for medical reasons. This form requests an exemption from the photo, the signature, or both, when the person cannot attend ServiceOntario or cannot have the photo or signature captured. The provider states whether the condition is permanent or subject to change, which brings a health reassessment in 5 years.