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

Adjustment

Ministry use

Provider Number

Health Number

Enter the first four digits - Enter the next three digits - Enter the next three digits Version

Date of Birth (yyyy/mm/dd)
Account Number
Payment Prog.
Payee
Location Code
Referred by
Facility Number
Inpatient Admission (yyyy/mm/dd)
Original Claim Number


Service Code	Fee Submitted	No. of Services	Service Date yyyy/mm/dd	Assessment Code	Diagnosis	Explanatory Code	Fee Approved	Adjustment Reason	Item No.	Action Code
1. Service Code	1. Fee Submitted	1. No. of Services	1. Service Date (yyyy/mm/dd)	1. Assessment Code	1. Diagnosis	1. Explanatory Code	1. Fee Approved	1. Adjustment Reason	1. Item No.	1. Action Code
2. Service Code	2. Fee Submitted	2. No. of Services	2. Service Date (yyyy/mm/dd)	2. Assessment Code	2. Diagnosis	2. Explanatory Code	2. Fee Approved	2. Adjustment Reason	2. Item No.	2. Action Code
3. Service Code	3. Fee Submitted	3. No. of Services	3. Service Date (yyyy/mm/dd)	3. Assessment Code	3. Diagnosis	3. Explanatory Code	3. Fee Approved	3. Adjustment Reason	3. Item No.	3. Action Code
4. Service Code	4. Fee Submitted	4. No. of Services	4. Service Date (yyyy/mm/dd)	4. Assessment Code	4. Diagnosis	4. Explanatory Code	4. Fee Approved	4. Adjustment Reason	4. Item No.	4. Action Code
5. Service Code	5. Fee Submitted	5. No. of Services	5. Service Date (yyyy/mm/dd)	5. Assessment Code	5. Diagnosis	5. Explanatory Code	5. Fee Approved	5. Adjustment Reason	5. Item No.	5. Action Code
6. Service Code	6. Fee Submitted	6. No. of Services	6. Service Date (yyyy/mm/dd)	6. Assessment Code	6. Diagnosis	6. Explanatory Code	6. Fee Approved	6. Adjustment Reason	6. Item No.	6. Action Code
7. Service Code	7. Fee Submitted	7. No. of Services	7. Service Date (yyyy/mm/dd)	7. Assessment Code	7. Diagnosis	7. Explanatory Code	7. Fee Approved	7. Adjustment Reason	7. Item No.	7. Action Code
8. Service Code	8. Fee Submitted	8. No. of Services	8. Service Date (yyyy/mm/dd)	8. Assessment Code	8. Diagnosis	8. Explanatory Code	8. Fee Approved	8. Adjustment Reason	8. Item No.	8. Action Code
9. Service Code	9. Fee Submitted	9. No. of Services	9. Service Date (yyyy/mm/dd)	9. Assessment Code	9. Diagnosis	9. Explanatory Code	9. Fee Approved	9. Adjustment Reason	9. Item No.	9. Action Code
10. Service Code	10. Fee Submitted	10. No. of Services	10. Service Date (yyyy/mm/dd)	10. Assessment Code	10. Diagnosis	10. Explanatory Code	10. Fee Approved	10. Adjustment Reason	10. Item No.	10. Action Code

Confidential when completed

4478–84 (2007/03) © Queen’s Printer for Ontario, 2007

fold here

Please detach here and return the top portion to the ministry. The bottom portion is a copy for your records.

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

Adjustment

Ministry use

Provider Number

Health Number

Enter the first four digits - Enter the next three digits - Enter the next three digits Version

Date of Birth (yyyy/mm/dd)
Account Number
Payment Prog.
Payee
Location Code
Referred by
Facility Number
Inpatient Admission (yyyy/mm/dd)
Original Claim Number


Service Code	Fee Submitted	No. of Services	Service Date yyyy/mm/dd	Assessment Code	Diagnosis	Explanatory Code	Fee Approved	Adjustment Reason	Item No.	Action Code
1. Service Code	1. Fee Submitted	1. No. of Services	1. Service Date (yyyy/mm/dd)	1. Assessment Code	1. Diagnosis	1. Explanatory Code	1. Fee Approved	1. Adjustment Reason	1. Item No.	1. Action Code
2. Service Code	2. Fee Submitted	2. No. of Services	2. Service Date (yyyy/mm/dd)	2. Assessment Code	2. Diagnosis	2. Explanatory Code	2. Fee Approved	2. Adjustment Reason	2. Item No.	2. Action Code
3. Service Code	3. Fee Submitted	3. No. of Services	3. Service Date (yyyy/mm/dd)	3. Assessment Code	3. Diagnosis	3. Explanatory Code	3. Fee Approved	3. Adjustment Reason	3. Item No.	3. Action Code
4. Service Code	4. Fee Submitted	4. No. of Services	4. Service Date (yyyy/mm/dd)	4. Assessment Code	4. Diagnosis	4. Explanatory Code	4. Fee Approved	4. Adjustment Reason	4. Item No.	4. Action Code
5. Service Code	5. Fee Submitted	5. No. of Services	5. Service Date (yyyy/mm/dd)	5. Assessment Code	5. Diagnosis	5. Explanatory Code	5. Fee Approved	5. Adjustment Reason	5. Item No.	5. Action Code
6. Service Code	6. Fee Submitted	6. No. of Services	6. Service Date (yyyy/mm/dd)	6. Assessment Code	6. Diagnosis	6. Explanatory Code	6. Fee Approved	6. Adjustment Reason	6. Item No.	6. Action Code
7. Service Code	7. Fee Submitted	7. No. of Services	7. Service Date (yyyy/mm/dd)	7. Assessment Code	7. Diagnosis	7. Explanatory Code	7. Fee Approved	7. Adjustment Reason	7. Item No.	7. Action Code
8. Service Code	8. Fee Submitted	8. No. of Services	8. Service Date (yyyy/mm/dd)	8. Assessment Code	8. Diagnosis	8. Explanatory Code	8. Fee Approved	8. Adjustment Reason	8. Item No.	8. Action Code
9. Service Code	9. Fee Submitted	9. No. of Services	9. Service Date (yyyy/mm/dd)	9. Assessment Code	9. Diagnosis	9. Explanatory Code	9. Fee Approved	9. Adjustment Reason	9. Item No.	9. Action Code
10. Service Code	10. Fee Submitted	10. No. of Services	10. Service Date (yyyy/mm/dd)	10. Assessment Code	10. Diagnosis	10. Explanatory Code	10. Fee Approved	10. Adjustment Reason	10. Item No.	10. Action Code

Confidential when completed