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

Request for Major Eye Examination

As of November 1, 2004, routine eye examinations for patients’ age 20 to 64 years are no longer an insured service.

Patients with any one of the following medical conditions are eligible to directly access a "major eye exam" service and do not need this form completed in order to obtain this service from their eye care provider.
Diabetes mellitus, type 1 or 2, Glaucoma, Corneal disease, Cataract, Retinal disease, Strabismus, Visual field defects, Amblyopia

Patients with any other medical conditions affecting the eye may access a "major eye exam" service once every 12 months upon recommendation by either a physician or a nurse practitioner working in a collaborative practice.

A fee of $10.00 (fee code E077) may be claimed for completing this request.

If you have a patient who requires a major eye exam service, please complete the following:

Section 1 – Patient Information

Name
Last Name
First Name
Middle Name

Health Number Version Code

Date of Birth
yyyy mm dd

Address
Apartment
Street Number and Name, or P.O.Box Number, R,R., General Delivery

City
Province Postal Code

Telephone No. ( ) –

Section 2 – Patient Medical Condition

Please provide medical information explaining why this patient would require a major eye exam service once every 12 months.

Section 3 – Physician / Nurse Practitioner Information

Name
Last Name
First Name

OHIP Billing Number

Address
Street / Box No.
Street Name
Unit
City
Postal Code

Contact No. ( ) –

In providing my signature, I verify that the information contained on this requisition is true and accurate to the best of my knowledge.

Signature

Date yyyy mm dd

Section 4 – Major Exam Provider Information

Optometrist / Physician Name
Last Name
First Name

This requisition is valid until March 31, five fiscal years after the date of physician/nurse practitioner signature.
A new requisition form may be provided prior to this expiry date if the patient is seeking a major eye exam from a provider other than the one noted in section 4.