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

EDT Registration
PO Box 68
Kingston ON K7L 5K1

Interdisciplinary Health Provider (IHP) Electronic Data Transfer (EDT)
Undertaking and Acknowledgement

The Ministry of Health and Long-Term Care’s collection of the information on this form is necessary for the proper administration of the Primary Care Nurse Practitioner Program and Family Health Teams initiatives. The information will be used to assess, verify and monitor eligibility for payment and conduct program evaluations. For information about this collection, call 1 866 766–0266, in Toronto 416 325–3575, or write to the Director, Primary Health Care Branch, 80 Queen Street, 3rd Floor, Kingston ON K7K 6W7.

Solo/Group Provider Number
Name

1. Name (please print)
Signature

Provider No. (if applicable)
Date

2. Name (please print)
Signature

Provider No. (if applicable)
Date

3. Name (please print)
Signature

Provider No. (if applicable)
Date

4. Name (please print)
Signature

Provider No. (if applicable)
Date

5. Name (please print)
Signature

Provider No. (if applicable)
Date

6. Name (please print)
Signature

Provider No. (if applicable)
Date

7. Name (please print)
Signature

Provider No. (if applicable)
Date

8. Name (please print)
Signature

Provider No. (if applicable)
Date

9. Name (please print)
Signature

Provider No. (if applicable)
Date

10. Name (please print)
Signature

Provider No. (if applicable)
Date

11. Name (please print)
Signature

Provider No. (if applicable)
Date

12. Name (please print)
Signature

Provider No. (if applicable)
Date

13. Name (please print)
Signature

Provider No. (if applicable)
Date

14. Name (please print)
Signature

Provider No. (if applicable)
Date

15. Name (please print)
Signature

Provider No. (if applicable)
Date

16. Name (please print)
Signature

Provider No. (if applicable)
Date

17. Name (please print)
Signature

Provider No. (if applicable)
Date

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

Interdisciplinary Health Provider (IHP) Electronic Data Transfer (EDT) Undertaking and Acknowledgement

Interdisciplinary Health Provider (IHP) Electronic Data Transfer (EDT)
Undertaking and Acknowledgement