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014-4792-67
Application for Funding Ventilator Equipment and SuppliesUsed to apply for Funding for Ventilator Equipment and Supplies014-4421-84
Reciprocal ClaimClaim card used by physicians to receive reimbursement for reciprocal claims4976-47
Healthcare Provider Notification of MedsCheck ServicesUsing the standardized fax template, pharmacists must share the completed MedsCheck Personal Medication Record with the patient's primary prescriber. A record of the successfully transmitted fax must be kept on file at the pharmacy.014-3975-87
Visudyne Therapy Registration/Funding EnrollmentApplication for reimbursement of cost due to use of Visudyneon00325
Application for Emergency Admission to Secure Treatment ProgramEmergency admission of a child to a secure treatment program.014-2772-87
Special Authorization (Allergen)Used for obtaining authorization for allergen exact as an ODB benefit014-4917-67
Vendor Registration ApplicationThe Vendor Registration Application form is an interactive form that will be completed by an Ontario retailer or supplier of assistive devices who is requesting registration with the Assistive Devices Program.014-4941-87
Exceptional Access Program (EAP) Request Fragmin (Dalteparin Sodium) TherapyThe purpose of the e-Form is to assist physicians in the EAP drug request process by integrating all the rules/criteria into an interactive e-Form that will ensure all the necessary information is captured.014-3759-83
Community Treatment Order (CTO) Report Logform used to provide patient with a comprehensive plan of community-based treatment or care and supervision.014-4971-67
Vendor AgreementThe Ministry of Health and Long-Term Care's Assistive Devices Program provides customer centered support and funding to Ontario residents who have long-term physical disabilities to provide access to personalized assistive devices appropriate for the individual's basic needs. To accomplish this goal the ADP establishes contracts with vendors in order to ensure that ADP funding for clients are in accordance with Program policies.014-4744-84
IHP Application for Direct Bank PaymentForm used by IHPs to set up direct bank deposit014-2743-84
Request for Approval of Payment for Proposed Dental Proceduresform completed to obtain approval for dental procedures to be carried out in hospital and covered by OHIP014-4474e-67
Prior Testing Disclosure - Powered Mobility DevicesThis form is used by Manufacturers to report testing of Powered Mobility Devices014-4316-84
Patient Enrolment Batch Headerform placed on top of bundles of primary care forms, to submit to ministry for processing.014-5048-45
AEMCA Examination ApplicationThe application form is for candidates who have either successfully completed the Paramedic training program provided by an approved College or Training Institution or have been considered equivalent through the MOH Standard Paramedic Equivalency Process and wish to write to write the Ministry of Health (MOH) Advanced Emergency Medical Care Assistant (AEMCA) examination.014-4550-88
Application for Tuition Support Program for NursesApplication form completed by nursing candidates to apply to Tuition Support Program for Nurses for financial incentives.014-4340-84
Primary Care - Time and Location of After Hours ServicesForm used to record hours of physicians in after hours clinics
