Government of Ontario: Ministry of Health

Primary Health Care
Enrolment Material Order Form

Print clearly and mail or fax the completed form to:
OSS Forms, Print and Distribution Primary Care Project
355 Carlingview Drive, Unit 4
Toronto ON  M9W 5G8
Tel: 1 888 295-5919
Fax: 1 888 295-5216
Email: PrimaryCareOSS@ontario.ca

Physician Information

First Name
Last Name
Name of Primary Health Care Group

Shipping Address

Unit No.
Street No.
Street Name
City/Town
Postal Code
Contact Name (First Name, Last Name)
Email Address
Telephone No.
Extension
Fax No.

Imprinting of Enrolment Materials

Imprint with physician's name and group name
Imprint with physician's name, group name and address (if different from shipping address, fill out address below)
No imprinting

Unit No.
Street No.
Street Name
City/Town
Postal Code

Enrolment Materials (Indicate items being requested)

Patient Enrolment and Consent to Release Personal Health Information form

Enrolment Kits

Reminder Post Cards (to be mailed out to the patients to follow-up on enrolment kits)

Business Reply Envelopes (to be used only for patients to return completed forms)

Patient Enrolment Batch Header - 25 Forms/Pad (Form 4316-84)

Request to Remove a Patient - 25 Forms/Pad (Form 3624-84)

New Patient Declaration - 25 Forms/Pad (Form 4367-84)

Unattached Patient Declaration - 25 Forms/Pad (Form 4431-84)

Patient Information Brochures are available in any of the following languages. Please specify language and quantity.

Order Confirmation

Group Registration No. (e.g. FXXX/BXXX)
Billing No.
Order Placed by
Date (yyyy/mm/dd)