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

Enrolment Processing Unit
PO Box 48
Kingston ON  K7L 5J3

Primary Health Care
Patient Enrolment Batch Header

Microfilm use only

Section 1 - Instructions

• Complete this “Primary Health Care Patient Enrolment Batch Header” form when submitting the forms listed below to the ministry. Each batch may include a maximum of 100 forms per batch.
• Place the Batch Header on top of each batch of forms and mail them to the ministry by the delivery method of your choice (e.g. regular or registered mail).
• Complete the information below using black or blue ball point pen.
• Send only the white (ministry) copies of the Patient Enrolment and Consent to Release Personal Health Information forms.
• Retain a copy of this batch header along with the pink copy of the Patient Enrolment and Consent to Release Personal Health Information forms.
• Remove the tear offs from the Patient Enrolment and Consent to Release Personal Health Information forms prior to sending.
• Ensure that all forms have been properly completed.
• Mail forms to the above address.

Section 2 - Batch Information

Note: Complete a separate batch header for each of the form types listed below.

Form type: Patient Enrolment and Consent to Release Personal Health Information forms
No. of forms
Form type: Request to Remove a Patient forms
No. of forms
Form type: Request to Change Designated Physician forms
No. of forms

Section 3 - Physician Information

Print physician information clearly or affix address label.

Name
Address

Billing no.
Group no.
Group name
Date submitted to ministry (yyyy / mm / dd)