Government of Ontario: Ministry of Health and Long-Term Care

Confirmation of Payment Instruction

Primary Health Care Team
Underserviced Area Program

159 Cedar Street, Suite 402
Sudbury ON P3E 6A5
Telephone: (705) 564-7280
Toll free: 1-866-727-9959

Account Holder’s Information

Account holder’s name

Address

Signature

Telephone no.

I/We authorize my/our payment be forwarded by deposit directly into the following account: (Please attach a blank voided cheque)
Institution no.*

Branch no.*

Account no.*

* from the MICR encoding on the cheque

Attach cheque here

Please return this confirmation and a voided blank cheque to:

Ministry of Health and Long-Term Care
Primary Health Care Team
Underserviced Area Program
159 Cedar Street, Suite 402
Sudbury ON P3E 6A5

The Ministry of Health and Long-Term Care is authorized to collect the personal information requested in this form for the purpose of properly administering the Ministry’s Underserviced Area Programs under subsection 6(1) paragraph 4 or clause 6(2)(b) of the Ministry of Health and Long-Term Care Act, R.S.O. 1990, c. M. 26. The personal information will be used to facilitate payment. For information about this collection, please contact Manager, Underserviced Area Program, at 159 Cedar Street, Suite 402, Sudbury ON P3E 6A5, telephone no. (705) 564-7280 or 1-866-727-9959.