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

Interdisciplinary Health Provider (IHP) Application for Direct Bank Payment

Please print.

Transaction Type New Change

A. Personal Data (Enter your Group Information)

Group No. Group Number
Group Name

B. Authorization for Direct Bank Payment from the Ministry of Health and Long-Term Care

I/We hereby authorize the Ministry of Health and Long-Term Care to make direct bank payment in the account indicated.

Solo Registration Last Name of Signee or Applicant
Initials
Applicant's Signature

Date (yyyy/mm/dd)
Telephone No.

Group Registration
One authorized signatory of the organization is required. Last Name of Signee or Applicant (must be an affiliate of group)
Initials
Applicant's Signature

Date (yyyy/mm/dd)
Telephone No.

C. Payment Data

Attach a blank voided cheque from the financial institution where you bank, with the fully micro-encoded branch, institution and account numbers. Note : Payment data will be used for Direct Bank Payment.

Bank Account in the Name of

Place voided cheque here.