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

Request for Approval of Payment for Proposed Dental Procedures

Confidential when completed

Instructions to Dentists

1. Forward all copies of this form to Medical Consultant c/o your Ministry of Health and Long-Term Care office.
2. Return your copy of this form with your claim card if request is approved.
3. Please print or type, you are making 2 copies.

Patient Information

Patient's last name and initials

Patient's first name

Patient's address

Postal Code

Date of birth (yr/ mo. / day)

Health Number
Version

Attending physician
Physician's address
Postal Code

Surgery Details

Name of hospital (Note: Surgical services must be provided in a public hospital graded under the Public Hospitals Act as a Group A, Group B, Group C or Group D hospital.)

Date of admission (if known)

Proposed fee

Diagnosis and proposed procedure (please print or type)

Medical indication for hospitalization (specify reasons for hospitalization and provide medical report when available)

Dentist’s Last Name

Dentist's address

Postal Code

Dentist's identification number

_________________________________________
Dentist's signature

Date

Ministry of Health and Long-Term Care Assessment

All approvals are subject to the following conditions:
Ontario Health coverage is in effect on date of service and that the services
are rendered in a Group A, Group B, Group C or Group D hospital.
1. Approved for benefits for proposed procedure(s) described above, specific only to those dental services listed in the Dental Schedule of Benefits under the Health Insurance Act.

2. Approved as amended (See comments)

3. Not approved as a benefit (Note: The hospitalization and the associated general anaesthesia for dental procedures performed in hospital are insured services, whether or not thedental procedures themselves are insured services under the Plan. The exception is the general anaesthesia for removal of impacted teeth when the extraction is not approvedas a benefit by the Ministry of Health and Long-Term Care.)

Comments

____________________________________________________
Signature for Ministry

Date

Part 1 - Dentist
Part 2 - Ministry of Health and Long-Term Care

Collection of the information is authorized under the Health Insurance Act, R.S.O. 1990, c.H.6, Regulation 552, Section 16. It will be used to assess eligibility for payment. For information about collection practices, contact the Director, Provider Services Branch (613) 548-6716 or your local Ministry of Health and Long-Term Care office.

For the Ministry of Health and Long-Term Care office nearest you,

Call 1 800 268-1154
In Toronto (416) 314-5518
For TTY 1 800 387-5559

Consult the government pages of your telephone book

Visit our Web site at www.health.gov.on.ca

7530-4871