Patient's last name and initials
Health Number
Version
M F
Patient's first name
yr.
mo.
day
Patient's address
Postal Code
Name and address of hospital
Date of admission (if known)
Proposed fee
Diagnosis and proposed procedure
Medical indication for surgery
Reason for referral outside Ontario
Surgeon's and/or referring physician's name in full
Surgeon's and/or referring physician's address
Surgeon's and/or referring physician's Ministry of Health and Long-Term Care identification number
Surgeon's and/or referring physician's signature
Date
1 and 2 pertain on condition that Ontario Health coverage is in effect on date of service.
1. Approved for benefits as submitted 2. Approved as amended 3. Not an eligible benefit Comments/Remarques
Signature for Ministry of Health and Long-Term Care
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)
0691-84 (00/03) 7530-4239
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 or Consult the government pages of your telephone book or Visit our Web site at www.gov.on.ca/health