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014-7521-84
Out of Province Out-patient Servicesform used for out-patient services incurred by visitors from another province014-4721-84
IHP Electronic Data Transfer (EDT) Undertaking and Acknowledgement for Nurse Practitioners (NP)Form used as part of EDT registration package for IHPs014-4342-84
Primary Care-List of Locations Where Group Serv. are Regularly ProvidedForm to show all group locations where physician services provided014-7179-84
Summary of Inpatient Expensesform sent to other provinces for reimbursement of inpatient claims paid (reciprocal)on00326
Emergency Admission to Secure Treatment ProgramThis form is completed by the person in charge of the secure treatment program once the criteria are met for the child's emergency admission to a secure treatment program.014-7698-84
Application for OHIP Direct Bank Payment for Health Care Professionalsform used so physicians can have direct deposit of payment of claims014-4752-84
Undertaking by Interdisciplinary Health Providers (IHP) for Participation in Machine Readable Input (MRI)Form that Interdisciplinary Health Providers will complete and sign agreeing to conform to ministry's technical specifications for claims submission in MRI014-2404-84
Claims Flagged for Manual Reviewform submitted with claims to provide additional information regarding particular claim014-4311-82
Health Card Re-RegistrationForm is generated by client communication system to have people replace red&white card with photo health card014-0280-82
Change of InformationForm used to change status of OHIP coverage - i.e., change of address, name, citizenship status, etc. or to cancel OHIP coverage or replacement of lost, stolen and damaged card014-4431-84
Primary Health Care Unattached Patient Declarationform used, in urgent cases (i.e. patient was in hospital, newborn in NICU) where patient has no family physician so can join primary group.014-4858-87
Request for Ilaris® (canakinumab)Application for drug funding014-4901-97
Requisition for NaloxoneRequisition for Naloxone014-4638-67
Authorizer Application - Attachment BAuthorizer Application - Attachment B014-4652-87
Request for Myozyme®014-1903-67
Statement of Support for Device Listing Wheelchairs, Positioning and Ambulation AidsThis 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.014-2983-88
Confirmation of Payment Instruction014-1819-67
Application for Equipment Listing Wheelchairs, Positioning and Ambulation AidsThis 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.014-0403-67
Application for Authorizer StatusApplication for Authorizer Status014-4955-64
Healthy Smiles Ontario – Authorizing or Cancelling a RepresentativePaper application required to register via mail. This form is submitted to authorize the MOHLTC (Oshawa) to deal with another person (such as your spouse or common-law partner, other family member, friend, or accountant) as your representative for HSO program matters.
