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on00314
Request for Prior Approval for Full Payment of Insured Out-of-Country (OOC) Health ServicesThis 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.014-0406-67
Authorizer Agreement with the Assistive Devices ProgramThe 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 must establish relationships with health professionals in order to ensure that ADP clients are assessed for cost-effective devices that best suit their needs.014-4406-87
Request for an Unlisted Drug Product - Exceptional Access Program (EAP)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.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.014-4931-87
Annual Deductible Re-Assessment RequestThis form is available on the Ontario Drug Benefit Program Online Applications and Forms website : https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.014-4929-87
Trillium Drug Program Application Signature RequestThis form is available on the Ontario Drug Benefit Program Online Applications and Forms website: https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.014-4423-87
Notification for Change of Information for Trillium Drug ProgramThis form is available on the Ontario Drug Benefit Program Online Applications and Forms website: https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.014-5050-67
Vendor Registration Application - Home Oxygen TherapyThe Vendor Registration Application form is an interactive form that will be completed by an Ontario retailer or supplier of home oxygen therapy who is requesting registration with the Assistive Devices Program.014-3384-83
Application for OHIP Billing Number for Health ProfessionalsPhysicians complete form to apply for OHIP billing number and/or specialty billing number.on00161
MOH CYMH Service Description SchedulesThe Service Description Schedule is part of the Transfer Payment Agreement between His Majesty the King in right of Ontario as represented by the Minister of Health (“the Province”) and the Transfer Payment Recipient. The Transfer Payment Recipient will deliver the programs and services in accordance with the requirements as outlined in this Service Description Schedule document in addition to all conditions and requirements within the Transfer Payment Agreement.014-4347-84
Request for Major Eye Examinationform to be completed by those eligible for eye exams to be covered under OHIP014-2743-84
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 OHIP014-7179-84
Summary of Inpatient Expensesform sent to other provinces for reimbursement of inpatient claims paid (reciprocal)014-1057-82
(Change of Address form) What's Your Address?Form used to update/change address information of OHIP cardholders014-4908-87
Initial Request for Compassionate Review PolicyTo help physicians to submit requests for drug funding for their ODB-eligible patients under the Compassionate Review Policy.on00502
Laboratory RequisitionLaboratory Requisition Pursuant to the Mandatory Blood Testing Act, 2006 and O. Reg. 449/07 To support implementation of the Mandatory Blood Testing Act, 2006014-4818-69
Long-Term Care Home Support Document List - Resident Receiving ODSPTo be used by residents of LTC homes who would like to apply for a reduction in the amount of their basic accommodation fees. This document guides applicants in determining which supporting documents will be required as part of their application. This document is to be used by applicants who are receiving benefits from the Ontario Disability Support Program.on00857
Specialty-Service Provider Form for Northern Health Travel GrantThis form is to be completed by a Specialty-Service Provider who provides an OHIP-insured service to a patient who is eligible for a Northern Health Travel Grant (NHTG). IMPORTANT: This form is to be used only for the purpose of patients looking to submit NHTG applications via the NHTG Online Form. This form must be included as an attachment and submitted via the NHTG Online Form, which you can access at the following location: https://forms.mgcs.gov.on.ca/dataset/on00817 If you wish to submit by mail, please complete the NHTG Application available on the ministry website: https://forms.mgcs.gov.on.ca/dataset/0327-88on00460
Physician/Nurse Practitioner ReportForm 1 - Physician/Nurse Practitioner Report Pursuant to the Mandatory Blood Testing Act, 2006 and O. Reg. 449/07 To support implementation of the Mandatory Blood Testing Act, 2006
