387 Forms found for health proxy form

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  • on00329
    Warrant to Apprehend and Return a Child Who has Been Admitted to a Secure Treatment Program

    Court Proceeding and to apprehend a child who has been admitted to a secure treatment program.

  • 014-4637-67
    Application for Rehabilitation Assessor/Fitter/Dispenser Status

    Application for Rehabilitation Assessor/Fitter/Dispenser Status

  • 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 Evidence

    To 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 Schedules

    The 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 Generator

    The "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 Information

    Healthy 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 Application

    Healthy 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 Dying

    The 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.

  • 014-4931-87
    Annual Deductible Re-Assessment Request

    This 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 Request

    This 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 Program

    This 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.

  • 016-0279
    Crane Operator's Medical Certificate

    Amendments 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 Guarantor

    Healthy 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 Therapy

    The 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.

  • 014-1903-67
    Statement of Support for Device Listing Wheelchairs, Positioning and Ambulation Aids

    This 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.

  • 014-1819-67
    Application for Equipment Listing Wheelchairs, Positioning and Ambulation Aids

    This 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.

  • 014-4955-64
    Healthy Smiles Ontario – Authorizing or Cancelling a Representative

    Paper 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.

  • 014-3233-87
    Seniors Co-Payment Program Application

    The Seniors Co-Payment Program Application 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 SCP at 416-503-4586 (Toronto area) or 1-888-405-0405 (outside Toronto) for a paper version of this form.

  • 014-3693-87
    Trillium Drug Program Application

    The Trillium Drug Program Application 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.