This form may be submitted to the Ministry of Health and Long-Term Care when the Health Number of a patient is not available.
Last Name First Name Middle Name
If an alternate last name is known, please provide
I agree to allow the health care provider/facility listed below to submit the information on this form to the Ministry of Health and Long-Term Care (MOHLTC).
I further agree to allow the MOHLTC to release my health card number to the health care provider/facility listed below so that the health care provider/facility can use my health card number to fulfill its reporting and accountability requirements with the MOHLTC.
If I choose not to provide my consent to this disclosure, it will not impact my access to services by the health care provider/facility listed below.
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.
A parent or guardian may sign for a child under 16 years of age. An attorney under continuing power of attorney, an attorney under power of personal care, or a legal guardian may also sign on behalf of an individual of any age.
Provider No.
Facility No.
The Health Number of the patient will be returned to the provider/facility listed here.
Provider/Facility Name and Address
Date Received Date Processed Processed by