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014-2859-69
Application for Services Form 1Application for services of a homemaker or a nurse014-2862-69
Medical Certificate Form 3Application used by First Nations and the North014-2861-69
Consent to Inspect Assets Form 2Used to determine whether a person who is eligible for homemaking and nurses services is required to pay the fees prescribed for the services.014-4500-69
Determination of Available Monthly Income Form 4Used for the determination of applicant's available monthly income.014-4723-87
Submission of Patient Evidence Patient Advocacy Groups - Registration FormTo allow patient advocacy groups to register into the database so that they provide written submissions to the ministry on a drug; the form is to make sure all the appropriate information is provided.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.014-1948-95
Application for Direct Bank Payment - ADPUsed by clients/vendors to receive remuneration by direct deposit versus cheque.014-4637-67
Application for Rehabilitation Assessor/Fitter/Dispenser StatusApplication for Rehabilitation Assessor/Fitter/Dispenser Status014-4591-87
Request for Elaprase®To facilitate physician's in making an EAP request for funding/reimbursement of Elaprase for Hunter's Syndrome.014-4717-87
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.014-4777-87
Request for Zavesca® - Niemann Pick Type C (NPC)To facilitate prescribers making reimbursement claims for treatment of Niemann Pick Type C (NIPC).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.
