What the 3164-84 is for
The form covers two situations. Some people can’t go to a ServiceOntario centre for medical reasons. Others can go but can’t have their photo or signature captured, for example while recovering from an accident or surgery. The patient chooses a photo exemption, a signature exemption, or both. It travels with a health card registration, renewal or re-registration form, and it doesn’t replace that form or the identity documents.
Who completes it
The health card holder, or their legal representative with proof such as a power of attorney, completes Part A: the exemption requested, health number, name and address, and a signed declaration. The physician or nurse practitioner completes Part B.
The patients who need this form are often the ones who can’t easily come in, so Part A is usually completed by a family member or substitute decision-maker. They pick up the printed form at the clinic, fill in Part A at home, and bring it back for you to complete Part B, or you complete Part B first and they finish the rest. In Medulla, you send Part A to the patient or their representative over a secure link. They fill it in on the form from any device, and when they send it back their answers are on the same PDF you complete Part B on, ready to print and sign for ServiceOntario.
How to fill in Part B
Assessment of condition
Give your professional opinion on the exemption the applicant requested. Mark the condition permanent, or subject to change, which requires a health reassessment in five years. Check that your answer fits the exemption ticked in Part A. A patient recovering from hand surgery may need a signature exemption that is subject to change, not a permanent one.
Health care provider information
Tick your college, the CPSO or the College of Nurses of Ontario for a registered nurse in the extended class. Print or stamp your name and address, add your college number and phone number, then sign and date.
Common reasons it’s sent back
- Part A unsigned, or signed by a representative with no proof of their authority.
- Neither permanent nor subject to change marked in Part B.
- Missing college number or college not ticked.
- Sent without the completed registration or renewal form.
- Photocopies of identity documents instead of the originals ServiceOntario requires.
Submitting and who pays
The patient or a representative brings the original form, the completed renewal form, and original proof of identity and Ontario residency to a ServiceOntario centre. They can also send them by registered mail or courier to the ServiceOntario address in Kingston, which mails back the new card and documents. The renewal is free. ServiceOntario’s pages say nothing about paying the clinician for Part B.