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014-4928-87
Updating Private Insurance 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.014-4930-87
Request to Remove a Household Member(s) from the 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.014-3523-87
Ontario Drug Programs Enrollment Form014-4940-87
Exceptional Access Program (EAP) Request OxyNEO (Oxycodone Hydrochloride Controlled Release) TabletsThe 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.014-4749-84
IHP Electronic Data Transfer (EDT) Undertaking and AcknowledgementForm related to EDT process for IHPs014-4943-87
Exceptional Access Program (EAP) Request Lovenox (Enoxaparin 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.014-4475e-67
Prior Testing Disclosure - Ambulation AidsThis form is used by Manufacturer's Testing Facilities to report testing of Ambulation Aids014-4942-87
Exceptional Access Program (EAP) Request Innohep (Tinzaparin 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.014-3715-82
Seasonal Agricultural Workers Registration for Ontario Health CoverageForm used to register specific migrant farm workers for OHIP number014-4917-67
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.014-4918-57
Request for Rights Advice Mental Health InpatientUsed by Mental Health Inpatient Unit staff to request Rights Advice. Form is completed when a physician issues a Mental Health Act form that requires the provision of Rights Advice. Fax form to the PPAO and Rights Adviser will be assigned014-4717-87
Submission of Patient EvidenceTo provide patient advocacy groups with a template for written submissions to the ministry on a drug; the form is to make sure all the appropriate information is provided.014-4442-97
Return Authorization for Resalable Drugs and Medical SuppliesUse this form if you ordered drugs and/or medical supplies from OGPMSS and wish to return resalable drugs and/or medical supplies to OGPMSS. OGPMSS will only accept returns and provide credit for resalable drugs or supplies that meet the criteria listed on the form. OGPMSS will provide you with a Return Authorization Number within 2 business days upon receipt of a completed form.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.014-3164-84
Health Card Medical Exemption RequestForm completed to request exemption, i.e., no photo to appear on photo health card014-4906-87
Fabry Disease Enzyme Replacement Therapy (Agalsidase) AssessmentApplication form for drug therapy for Fabry disease014-4907-87
Fabry Disease Enzyme Replacement Therapy (Agalsidase) RenewalRenewal form dor drug therapy for Fabry disease014-4956-64
Healthy Smiles Ontario – Change of InformationHealthy Smiles Ontario Change of Information form is a paper form submitted by mail as a result of a change during any benefit year. This form is used to add or change information about the applicant, marital status and/or spouse, and children/youth. This form is only required for those who have applied and been enrolled in the core services stream of the program.014-4473e-67
Prior Testing Disclosure - Manual WheelchairThis form is used by Manufacturer's Testing Facilities to report testing of Manual Wheelchairs.
