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

Application for Interdisciplinary Health Provider (IHP) Claims
Submission and Remittance Advice (RA) in Machine Readable Input (MRI)

Please type or print.

Part A : Service Provider/Group Data

Name
Registration Number
Street Number and Name
City
Province
Postal Code

Part B : Media of Claims Submission and Remittance Advice

Part C : Billing Agent Information (complete only if applicable)

Name of Billing Agent
Name of Contact
Street Number and Name
City
Province
Postal Code

Send notification of deleted claims (Error Report) to above Billing Agent.

Note : The RA for an individual service provider will be forwarded to the billing agent. The local Ministry of Health and Long-Term Care office must be notified thirty (30) days prior to a change in billing agent to ensure the service provider's data is forwarded to the correct location.

The first RA will be provided the month following receipt of the first claims submission.

Part D : Machine Readable Input/Output Delivery/Pick-up Location

To minimize the risk of damage, it is suggested that the MRI be delivered to your local Ministry of Health and Long-Term Care office. The Ministry of Health and Long-Term Care does not cover courier service expenses incurred for diskette packages delivered to your office.

Part E : Signature

Instructions

• 1. This application must be signed and submitted with the Undertaking by IHP for Participation in MRI (form no. 4752–84).
• 2. An Undertaking by IHP for Participation in MRI (form no. 4752–84) must be signed by each affiliate of a group.
• 3. Applications submitted by a third party (e.g. Group Administrator, Director, President, Owner, Licensee, etc.) must indicate the name and title of such party.

Name
Position or Title
Signature

Date

Ministry use only

Operator no.
Alpha Id.