IMMIGRATION

Canada

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Citizenship andImmigration Canada

Citoyenneté etImmigration Canada

This application is made available free by Citizenship and Immigration Canada and is not to be sold to applicants.

IMM 5568E (09-2007)

Application for IFH CoverageExtension

Table of Contents

Overview . . . . . . . . . . . . . . . . . . . . . . . . . 3

Who is eligible . . . . . . . . . . . . . . . . . . . . . 3

When to apply . . . . . . . . . . . . . . . . . . . . . 4

How to apply. . . . . . . . . . . . . . . . . . . . . . . 4

Where to send your application . . . . . . . . 4

If you move. . . . . . . . . . . . . . . . . . . . . . . . 4

How to complete the forms. . . . . . . . . . . . 5

What happens next . . . . . . . . . . . . . . . . . 7

Appendices

A – Information for health professionals: Medical benefits

B – Information for health professionals: Den-tal care

C – Photo Specifications

D – List of CIC offices

Forms

Application for IFH Coverage – Extension (IMM 5564)

Use of a Representative (IMM 5476)

2 Applyication for IFH coverage – Extension

Contact Information

Web siteFor 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 CanadaIf 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 your call.

If you need to speak to an agent, you must call Monday to Friday between 8 a.m. and 4 p.m. local time.

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 CanadaIf 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.

From anywhere in Canada, call 1-888-242-2100 (toll-free)

This publication is available in alternative formats upon request.

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.

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 and complete your application as neatly as possible. 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 eligibleOnly persons belonging to one of the following categories who are unable to pay for essential and emergency healthcare and who are not covered (see Note below) by a public or private health insurance plan 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.

Applying for IFH coverage – Extension 3

When to applyCitizenship 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 applyEach 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 C). 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 applicationPlace your forms and all support documentation in an envelope and mail them to the nearest Citizenship and Immigration Centre listed at Appendix D. Be sure to use sufficient postage on the envelope.

If you moveIf 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.

4 Applying for IFH coverage – Extension

How to complete the forms

Since most of the questions are clear, we provide instructions or clarifications only when needed. Please print clearly.

Application for IFHP Coverage – Extension(IMM 5564)

Section AClient 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 BIf 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 CComplete Section C only if you filed a refugee protection claim in Canada.

Section DIf 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 EPlease 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.

Applying for IFH coverage – Extension 5

There are two types of 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 youPaid 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 your behalf.

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 individualsTo authorize CIC to release information from your case file to someone other than 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/information/applications/release-info.asp and from Canadian embassies, high commissions and consulates abroad.

The person you designate will be able to obtain information on your case 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.

6 Applying for IFH coverage – Extension

What happens nextIf 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 (see Appendices A and B for additional information. Note that the list provided with the certificate may differ from the one appearing in the appendices).

If your application for an extension is denied, the CIC centre will notify you in writing.

Applying for IFH coverage – Extension 7

Appendix A

Interim federal health program (IFH) information for health professionals

Benefits: Medical

Services covered without CIC approval • Essential health services only for the treatment and prevention of serious medical/dental

conditions (see dental regulations).• Contraception, prenatal and obstetrical care.• Essential CPS prescription medications (or life supporting over-the-counter drugs such as

insulin or nitro). Must be lowest cost alternatives. Only drugs featured on the IFH medication list found at “www.fasadmin.com” are covered without prior approval.

• Professional fees as per applicable provincial health care plan. Fee codes (where applicable) must be supplied. Invoices must be submitted within six months of service.

• The Immigration Medical Examination is performed by an authorized Designated Medical Practitioner – reimbursed only for IFH eligible individuals who cannot afford the costs.

Services covered with CIC approval only • Complete physical examination/ counselling services by a general practitioner.• Ambulance/medical transport (unless emergency).• Diagnostic services (surgical, laboratory, or x-ray) when no significant medical short-term

complications are foreseen. • Certain high cost medications (e.g. Imitrex, Accutane, Interferon and Lamisil).• Allergy testing/desensitization.• Plastic surgery for esthetic purposes.• Elective surgery (e.g. hernia repair, joint replacements).• High cost procedures (e.g. organ transplantations). • Office-based psychotherapy by a psychiatrist after the initial consultation.• Psychotherapy by psychologists/general practitioners.• Physiotherapy.• Prosthetic or mechanical devices including hearing devices. • Eyewear. Visual acuity tests needed for all patients.

Requests for prior approval must be submitted by mail or fax to: Medical Director, IFH/CIC219 Laurier Ave. West, 3rd FloorOttawa, Ontario K1A 1L1FAX: 1-800-362-7456

Applying for IFH coverage – Extension A – 1

Services not covered under the IFH Program • Routine medical/eye exams.• Infertility investigations and treatment.• Routine circumcision of the newborn.• Chiropractic care.• Alternative/complementary medicine.• Most over-the-counter medications even when written on a doctor’s prescription.

Invoices to be sent by the health care providers only to: FAS Benefit Administrators Ltd9707- 110 Street, 9th floorEdmonton, Alberta T5K 3T4Fax: 780 452 5388Email : info@fasadmin.com

Note: If FAS does not already possess patient’s eligibility, you must send a copy of the eligibility document. The health provider can check this by telephone at 1-800-770-2998.

A – 2 Applying for IFH coverage – Extension

Appendix B

Interim federal health program (IFH) information for health professionals

Dental care

ONLY EMERGENCY DENTAL SERVICES ARE COVEREDEmergency dental services are defined as urgent procedures to alleviate pain, active infection, hemorrhage, and/or the results of oral trauma.

A maximum coverage of $400 exists during the patient’s eligibility period. A maximum of two teeth may be treated per visit. Dentists may verify the remaining funds available for a refugee by calling toll free 1-800-770-2998. If the limit has been exceeded, special approval must be obtained prior to the provision of services.

This funding is intended to cover only the following:

• Emergency exams (limit of once per six months per office). Complete oral exams and recall exams are not covered.

• Panoramic radiograph OR eight peri-apical X-rays (but not both) will be allowed during the entire eligibility period. X-rays must be clear, discernible and properly labelled or they will be returned. Bite-wing X-rays are not a covered expense.

• Prior approved permanent fillings are restricted to: 1) non-bonded amalgam on molars and bicuspids 2) bonded composite resin fillings on anterior teeth. Fillings will be paid on a continuous basis only. Routine dental treatment and incipient decay not observable in the X-ray are not covered.

• Scaling and root planning are not covered. • Uncomplicated extractions (two- teeth maximum per visit). Complex extractions require

pre-treatment radiographs and pre- determinations.• Drug prescriptions (only those needed to treat emergency conditions).• Prosthetics covered with prior approval only: transitional partial dentures. Relining for

dentures will be considered only after six months of placement of transitional dentures. All prosthetic requests should be accompanied by a completed « dental predetermination form » and submitted with either eight peri-apical X-rays or a panoramic X-ray.

• All anaesthetic care must be submitted for predetermination. For anaesthetics involving patients under the age of 13 years, four units may be approved. For patients aged 13 and older, up to eight units may be approved.

Exclusions to dental care: • root canal treatments;• permanent prosthetics and orthodontics;• intravenous sedation and nitrous oxide;• prophylaxis and fluoride treatments; • facility fees; and• specialist fees.

Applying for IFH coverage – Extension B – 1

Fees Payments will be made at 100% of the applicable current general practitioner provincial/territorial dental fee guide (lowest applicable fee). Predetermination requests should be mailed (with X-rays and all relevant fee codes) to FAS Benefit Administrators Ltd.

B – 2 Applying for IFH coverage – Extension

Appendix CPhoto Specifications

Notes to the applicant

• 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

TAKE THIS WITH YOU TO THE PHOTOGRAPHER

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35 mm (1 3/8”)

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Appendix D

Citizenship and Immigration Centres

ATLANTIC

Charlottetown 134 Kent Street, Suite 410National Bank TowerCharlottetown, PE C1A 8R8

Fredericton495 Prospect AvenueFredericton, NB E3B 9M4

Halifax1741 Brunswick Street, Suite B110Halifax, NS B3J 3X8

Moncton860 Main Street, 6th Floor, Suite 602Moncton, NB E1C 1G2

Saint John189 Prince William StreetSaint John, NB E2L 2B9

St. John’sNorth Atlantic Building, 2nd floor31 Pippy PlaceP.O. Box 13667, Station “A”St. John's, NL A1B 4G1

QUEBEC

Gatineau259 St-Joseph Blvd, Suite 109Gatineau, QC J8Y 6T1

Montréal1010 St-Antoine St. West, 2nd floorMontréal, QC H3C 1B2

Québec320 St-Joseph Street East, RC-118Québec, QC G1K 8G5

Sherbrooke76 Place de la CitéSherbrooke, QC J1H 4G8

Trois-Rivières55 des Forges Blvd., Room 012Trois-Rivières, QC G9A 6A8

ONTARIO

Greater Toronto Area, including Etobicoke, Mississauga and Scarborough25 St. Clair Avenue East, Suite 200Toronto, ON M4T 1M2

Outside the Greater Toronto AreaSend your application to the closest CIC as follows:

Barrie48 Owen Street, Suite 312Barrie, ON L4M 3H1

Hamilton 55 Bay Street NorthHamilton, ON L8R 3P7

KitchenerWaterloo/Wellington CIC29 Duke Street. EastKitchener, ON N2H 1A2

London 417 Exeter RoadLondon, ON N6E 2Z3

Niagara Falls 6080 McLeod Road, Unit 12Niagara Falls, ON L2G 7T4

Oshawa

78 Richmond Street West, 2nd floorOshawa, ON L1G 1E1

Ottawa (includes Kingston)200 Catherine Street, Suite 101Ottawa, ON K2P 2K9

Sault Ste. Marie22 Bay StreetSault Ste. Marie, ON P6A 5S2

Sudbury19 Lisgar Street, Room 305Sudbury, ON P3E 3L4

Thunder Bay 221 Archibald St. North, Suite 108Thunder Bay, ON P7C 3Y3

Windsor1250 Walker RoadWindsor, ON N8Y 4T4

Applying for IFH coverage – Extension D – 1

PRAIRIES/NORTHERN TERRITORIES

Calgary Harry Hays Building, Room 170220 4th Avenue S.E.Calgary, AB T2G 4X3

Edmonton(including residents of Northwest Territories)Suite 240, Canada Place9700 Jasper AvenueEdmonton, AB T5J 4C3

Regina 1783 Hamilton Street, Room 220Regina, SK S4P 2B6

Saskatoon 660 - 410 22nd Street EastSaskatoon, SK S7K 5T6

Winnipeg (including residents of Nunavut)Johnston Terminal, Room 40025 Forks Market RoadWinnipeg, MB R3C 0S9

BRITISH COLUMBIA/YUKON

Kelowna202- 1635 Abbott StreetKelowna, BC V1Y 1A9

Nanaimo60 Front Street, Room 201ENanaimo, BC V9R 5H7

Prince George250 – 177 Victoria StreetPrince George, BC V2L 5R8

Vancouver1148 Hornby StreetVancouver, BC V6Z 2C3

Victoria816 Government Street, Room 377Victoria, BC V8W 1W9

Whitehorse300 Main Street, Suite 215Whitehorse, YT Y1A 2B5

D – 2 Applying for IFH coverage – Extension