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014-4846-87
Request for Aldurazyme®To facilitate prescribers making reimbursement claims for treatment of Hurler-Scheie and Hurler disease014-1668-69
Application for a Licence to Establish or Maintain and Operate a Nursing HomeApplication for a Licence to Establish or Maintain and Operate a Nursing Home014-4750-84
Application for IHP GONet Electronic Data Transfer (EDT) ServiceIHPs apply to submit claim information via EDT4969-47
Diabetes Education ChecklistThe MedsCheck for Diabetes includes an Annual review that involves using the pharmacist's worksheet and providing the patient with a MedsCheck Personal Medication Record; as well as using a Diabetes Education Checklist and providing the patient with a Diabetes Education Patient Take-Home Summary.4974-47
Patient Take Home SummaryPharmacists may provide patients with a MedsCheck Patient Take-Home Summary that is intended to further engage patients in identifying ways to build added awareness in their drug therapy and help to identify therapy-related goals.4968-47
Personal Medication RecordUsing 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.014-4896-64
Notice of Transfer from a School - Immunization of School Pupils ActNotice of Transfer from a School - Immunization of School Pupils Act014-0225-47
Funding Enrollment for E.S.R.D. PatientsTo register ESRD patients for Special Drug Program for provision of Eythropoietins.on00329
Warrant to Apprehend and Return a Child Who has Been Admitted to a Secure Treatment ProgramCourt Proceeding and to apprehend a child who has been admitted to a secure treatment program.014-4591-87
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.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.on00536
Low-Volume Claim Submission Claim File GeneratorThe "Low-Volume Claim Submission Claim File Generator" is a tool that allows registered Health Care Professionals/Registered Third-Party Billing Agencies (RTPBAs) to generate a claim file that can be securely submitted to the ministry electronically for the purpose of payment.014-4956-64
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.014-4953-64
Healthy Smiles Ontario - General ApplicationHealthy Smiles Ontario General Application form for the core services stream of the program. This form applies to applicants that have a valid SIN and have filed a statement of income or a tax return with the CRA.014-3889-22
Clinician Aid A - Patient Request for Medical Assistance in DyingThe use of this aid is voluntary. It is being provided to assist you in making a written request for medical assistance in dying that complies with the legal requirements. Once you complete this request, you should provide it to your doctor or nurse practitioner. The completed aid may be included in your medical records and may be used by your doctor or nurse practitioner to provide health care to you.016-0279
Crane Operator's Medical CertificateAmendments to Regulation 854 for Mines and Mining Plants made under the Occupational Health and Safety Act, which came into effect on January 1, 2012, included changes to the medical certificate prescribed under section 195 of the regulation. Under these provisions, operators of cranes are required to undergo a yearly medical examination by a physician. The certificate, which is completed by the physician, provides a convenient way for stakeholders to comply with these requirements. The certificate will take less than five minutes to complete.on00026
Healthy Smiles Ontario - Application Through GuarantorHealthy Smiles Ontario Application Through Guarantor form for the core services stream of the program. This form applies to applicants who do not have a valid SIN or have not filed taxes with the CRA, and a guarantor is required to support registration and eligibility adjudication.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.
