Government of Ontario: Ministry of Health and Long-Term Care

Application for Reduction of Assessed Co-payment Fees

Application by the patient as a patient with a spouse in the community who does not qualify as a dependent

or an

Application by the spouse in the community who does not qualify as a dependent

This form is to be used for a patient who is seeking a reduction to the co-payment or for whom a reduction is sought further to the factors set out in section 10 of Reg. 552 under the Health Insurance Act. The application for the reduction may be requested by the patient, the spouse, the patient's attorney under a continuing power of attorney or guardian of property.

To be completed by the Hospital

Patient Information

Name of applicant

Health Number

Name of spouse

Address of spouse

Calculation of monthly income for spouse in the community who does not qualify as a dependant

1. OAS (Federal Old Age Security)

2. GIS (Federal Guaranteed Income Supplement)

3. GAINS (Ontario Guaranteed Annual Income Supplement)

4. Spouse's allowance

5. Salaries or wages

6. Annuities, superannuation, insurance benefits

7. Earned interest

8. Canada Pension Plan, Quebec Pension Plan

9. Workers' Compensation

10. Foreign pensions/US social security

11. Privately administered trust

12. Mortgage/Loan agreement

13. Farm or business

14. Rental of property

15. Support payments

16. Other

17. Total monthly estimated income

18. Maximum monthly amount of OAS, GIS and GAINS benefits available to a single person as at April 1 of the current year

19. Maximum benefit

20. Total (of items 18 and 19)

21. Total monthly estimated income for spouse, item 17 from above

22. Subtract the amount of item 21 from amount found in item 20. If the answer is less than zero, enter 0

23. Monthly reduction: enter the lesser of the amount in item 22 and $152.08 ($5.00 per day)

24. Co-payment for patient based on "Co-paymentCalculationss for 3264-54"

25. Monthly co-payment is the amount in item 24 less the amount in item 23

Monthly co-payment calculated above (item 25)

Daily co-payment rate is monthly co-payment divided by 30.4167

Name of staff member of institution

Position title

I/We understand the eligibility criteria. I/We have supplied the information in this application to the best of my/our knowledge and belief. All statements are true and no information required to be given has been withheld or omitted.

Should a reduction be granted on the basis of information in this application, I/We will notify the hospital administrator or his/her representative as the case may be, of any change of relevant circumstances pertaining to income.

I/We acknowledge that the information contained in this application may be used for the purposes of verifying eligibility for, and determining the reduction and I/we undertake to provide any information that my be required.

Signature of patient

Date

Signature of spouse

Date

7530-5434