Government of Ontario: Ministry of Health

Primary Health Care Unattached Patient Declaration

Do not mail this form to the ministry. This form must remain in the physicians office for audit purposes.

Please complete this form if you were an in-hospital patient, previously without a family physician, have been discharged from hospital and you have been accepted into the practice of a primary care physician and have signed a Patient Enrolment and Consent to Release Personal Health Information form. If you are signing on behalf of a child or dependent adult and have completed a Patient Enrolment and Consent to Release Personal Health Information form on their behalf, complete the applicable sections below.

Declaration

I am signing on behalf of (check the applicable boxes) Myself
The child listed below of whom I am the parent or guardian
The dependent adult listed below for whom I have a power of attorney for personal care

I hereby declare that the patient named below does not have a family
physician due to one or more of the following circumstances:
(check applicable boxes) The patient's family physician has moved to another community.
The patient has moved to another community.
The patient's family physician is no longer available due to illness/death/retirement.
The patient's family physician is no longer available due to change of practice type.
Up until now the patient has not had or felt the need for a family physician.

Sections A to C to be completed by patient / parent / guardian

Section A: Patient Information

patient is a child or dependent adult
First Name
Last Name
Health Number

Section B: Hospital Stay Information

Name of Hospital
Discharge Date yyyy/mm/dd

Section C: Patient / Guardian Signature and Date

Signature

Date yyyy/mm/dd

Section D: Physician Signature and Date (to be completed by physician)

I declare that to the best of my knowledge the above patient is not a patient of mine nor of any other family physician.

I also declare that the newborn listed is one that was admitted to a Neonatal Intensive Care Unit (NICU) within the last three months and is not a newborn of any existing enrolled or non-enrolled patient of mine or of any other physician.

I declare that the patient was an acute care patient in hospital, previously without a family physician and I accepted the patient into my practice, by enrolling the patient with the Patient Enrolment and Consent to Release Personal Health Information form within three months of his/her discharge from an in-patient hospital visit.

I agree to accept the above-noted patient into my practice and to provide ongoing primary health care to the patient from the date of this document. I will keep this document available on file in my primary office location and will provide copies of the same to the Ministry of Health as required for verification purposes.

Physician Last Name (print)

Physician First Name (print)

Physician Signature

Date yyyy/mm/dd

4431-84 (2022/11)

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