I, a legally qualified,
lawfully entitled to practise in the Province of Ontario, and duly registered with the Ministry of Health and Long-Term Care (MOHLTC) for the purpose of submitting service encounters, undertake :
That data pertaining to all service encounters rendered by the above noted and submitted in MRI will conform to the technical specification criteria and conditions governing the acceptance of claims submissions in MRI.
That where I propose to cease to submit service encounter data in MRI for any reason, I will notify the MOHLTC to that effect and will cease to submit service encounter data in MRI sixty (60) days after written notice to that effect is received by the MOHLTC.
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.
(Print Name) (Signature) (Ministry Provider Number) (Date)