Government of Ontario: Ministry of Health

700 - 75 Albert Street
Ottawa ON K1P 5Y9
613 545–0656

Out of Province In-Patient Standard Ward Costs

Page of

Hospital name

Location

Province of Residence

Prov. Code

Facility No.

Month Ending

Line No. 1

Plan Registration No
Expiry Date shown on Card (yyyy/mm/dd)

Patient’s surname (for married Quebec female residents, surname at birth), first name, address

Surname
First Name
Address
City
Prov.
Postal Code

Date of Birth (yyyy/mm/dd)
Sex
ICD–10
CCI
Death
Long–stay
Newborn
Declaration
Accident E code
Date of Admission (yyyy/mm/dd)
Date of Separation (yyyy/mm/dd)
Total days
Standard Ward Rate
Amount

Line No. 2

Plan Registration No
Expiry Date shown on Card (yyyy/mm/dd)

Patient’s surname (for married Quebec female residents, surname at birth), first name, address

Surname
First Name
Address
City
Prov.
Postal Code

Line No. 3

Plan Registration No
Expiry Date shown on Card (yyyy/mm/dd)

Patient’s surname (for married Quebec female residents, surname at birth), first name, address

Surname
First Name
Address
City
Prov.
Postal Code

Line No. 4

Plan Registration No
Expiry Date shown on Card (yyyy/mm/dd)

Patient’s surname (for married Quebec female residents, surname at birth), first name, address

Surname
First Name
Address
City
Prov.
Postal Code

Totals

Total days
Amount