Physicians complete form to indicate their preference on how malpractice reimbursement will be sent to them.

The Notice of Adverse Test Results and Issue Resolution form is to be used by licensed laboratories and owners/operators of small drinking water systems to support required written notifications pertaining to small drinking water system adverse water quality incidents (AWQI).

This form is used by manufacturers/distributors of mobility equipment (wheelchairs and wheeled walkers) for the purpose of making application to the Assistive Devices Program requesting approval to list their respective products on the list of approved devices.

Form will be used for NPs to become affiliated with an organization and participate in the NP Service Encounter Tracking and Reporting (SERT) Initiative to receive funding from the MOHLTC

Complete this form if you wish to have the Ministry of Health and Long-Term Care restrict access to your laboratory test information in the Ontario Laboratories Information System (OLIS) after your lab test has been completed.

Physicians complete form to apply for OHIP billing number and/or specialty billing number.

The Laboratory Services Notification (LSN) form is to be used by small drinking water system owners/operators to notify the local public health unit in writing as to which licensed laboratories will test drinking water samples for their small drinking water systems.

Certificate of Death – Form 1 to be completed by an attending physician or registered nurse in the extended class pursuant to s. 17(2)(a) of Reg. 965 – Hospital Management made under the Public Hospitals Act.

Under Interprovincial agreement, for travel within Canada, patients/physicians submit form to get reimbursed by applicable health plan.

This form is an order completed by the Chair of the Child and Family Services Review Board either releasing the child from the secure treatment program or denying the application.

he purpose of this form is to collect necessary information to obtain authorized consent and assure identity, under the Freedom of Information and Protection of Privacy Act (FIPPA), for application of services delivered by the Ministry of Health on your behalf (or for a “Health Care Group” in which you are a registered member), including: • Application for an OHIP Billing Number • Changes to Health Care Group Registration Information

The Small Drinking Water System Identification form is to be used by owners of small drinking water systems to notify in writing the medical officer of health in the health unit where their system is located before supplying drinking water to users of the system following construction or alteration of the small drinking water system or following a shut-down of the system that lasts longer than seven days.

You may use this application form to apply for the Ontario Seniors Dental Care Program if you do not have a valid Social Insurance Number (SIN) and/or if you have not filed your Personal Tax Return(s) with Canada Revenue Agency (CRA) for the most recent tax year. If you have a spouse (married or common law partner) who would also like to apply for the Program, they must complete their own application form.

You may use this application form to apply for the Ontario Seniors Dental Care Program if you and your spouse (if applicable) have filed your Personal Tax Return(s) with Canada Revenue Agency (CRA) for the most recent tax year and have a valid Social Insurance Number (SIN). If you have a spouse (married or common law partner) who would also like to apply for the Program, they must complete their own application form.

This form is meant to be submitted by a practicing Ontario physician on behalf of their patients to request consideration of funding for out-of-country health services. Along with the completed application form, submissions must also include relevant medical documentation.

This form is only to be used by prescribers to request an exemption for Ontario’s Biosimilar Switch Policy for a patient who HAS BEEN USING AN ORIGINATOR BIOLOGIC REIMBURSED THROUGH THE ONTARIO DRUG BENEFIT (ODB) PROGRAM previously authorized through the Exceptional Access Program and is unable to switch from an originator biologic or who is requesting to switch back to the originator following biosimilar switch.

For faster decisions, prescribers can use the SADIE online portal to submit requests to the Exceptional Access Program (EAP). Sign in through GO Secure (https://www.ebse.health.gov.on.ca) and select SADIE from the services drop-down menu. Visit the SADIE website for more information: http://www.ontario.ca/sadie. Alternatively, this form can be used for submitting requests to the EAP by fax.

Transfer of ownership of Integrated Community Health Services Centre (ICHSC) licence.

Used by Canadian board -certified orthotists registered with ADP to request funding for custom -made orthoses

Used to apply for Funding for Visual Aids