Government of Ontario: Ministry of Health

700 - 75 Albert Street
Ottawa ON K1P 5Y9

Out of Province Out-patient Services

Page of

Hospital name

Location

Province of Residence

Prov. Code

Facility No.

Month Ending

Line no. 1

Plan Registration No.
Expiry Date shown on Card (yyyy/mm/dd)

Patient’s Personal Information
Patient’s surname (for married Quebec, female residents, surname at birth), first name

Surname
Given Name
Date of Birth (yyyy/mm/dd)
Sex

Date of Service (yyyy/mm/dd)
Service Code
ICD–10
CCI
Cost per Service

Line no. 2

Plan Registration No.
Expiry Date shown on Card (yyyy/mm/dd)

Patient’s Personal Information
Patient’s surname (for married Quebec, female residents, surname at birth), first name

Surname
Given Name
Date of Birth (yyyy/mm/dd)
Sex

Date of Service (yyyy/mm/dd)
Service Code
ICD–10
CCI
Cost per Service

Line no. 3

Plan Registration No.
Expiry Date shown on Card (yyyy/mm/dd)

Patient’s Personal Information
Patient’s surname (for married Quebec, female residents, surname at birth), first name

Surname
Given Name
Date of Birth (yyyy/mm/dd)
Sex

Date of Service (yyyy/mm/dd)
Service Code
ICD–10
CCI
Cost per Service

Line no. 4

Plan Registration No.
Expiry Date shown on Card (yyyy/mm/dd)

Patient’s Personal Information
Patient’s surname (for married Quebec, female residents, surname at birth), first name

Surname
Given Name
Date of Birth (yyyy/mm/dd)
Sex

Date of Service (yyyy/mm/dd)
Service Code
ICD–10
CCI
Cost per Service

Line no. 5

Plan Registration No.
Expiry Date shown on Card (yyyy/mm/dd)

Patient’s Personal Information
Patient’s surname (for married Quebec, female residents, surname at birth), first name

Surname
Given Name
Date of Birth (yyyy/mm/dd)
Sex

Date of Service (yyyy/mm/dd)
Service Code
ICD–10
CCI
Cost per Service

Line no. 6

Plan Registration No.
Expiry Date shown on Card (yyyy/mm/dd)

Patient’s Personal Information
Patient’s surname (for married Quebec, female residents, surname at birth), first name

Surname
Given Name
Date of Birth (yyyy/mm/dd)
Sex

Date of Service (yyyy/mm/dd)
Service Code
ICD–10
CCI
Cost per Service

Total cost of services (Total cost of services= cost per service from line no. 1,2,3,4,5,6)

Hospital Certification
I certify that the health insurance identification cards of the patients listed above have been examined and the patient’s home address in each case appears on the hospital records.

Authorized signature
Date

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