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

Request for Approval of Payment for Proposed Surgery


Birth date

Surgery Details

Surgeon's and/or referring physician's address

Ministry of Health and Long-Term Care Assessment

1 and 2 pertain on condition that Ontario Health coverage is in effect on date of service.

This authorization is valid for one year after date of approval.
Instructions to surgeons/physicians:
1. Forward all copies of this form to Medical Consultant c/o your Ministry of Health and Long-Term Care office.
2. Please advise Assistant and Anaesthetist of status of claim. (that Approval has to be requested).
3. Return your copy of this form with your claim card if request is approved.
4. Please print or type, you are making 4 copies.

Part 1 - Surgeon
Part 2 - Patient
Part 3 - Ministry of Health and Long-Term Care
Part 4 - Hospital

(See reverse / Au verso)

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Collection of the information on this form is authorized under the Health Insurance Act, R.S.O. 1990, c.H. 6, Regulation 552, Preamble to Schedule 15. It will be used to assess eligibility for payment. For information about collection practices, contact the Director, Provider Services Branch at (613) 548-6716.

For the Ministry of Health and Long-Term Care office nearest you
please call 1 800 268-1154
In Toronto (416) 314-5518
For TTY 1 800 387- 5559

Consult the government pages of your telephone book

Visit our Web site at

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