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

Interdisciplinary Health Provider (IHP) Nurse Practitioner (NP) Authorization for Participation in the NP Service Encounter Reporting and Tracking (SERT) Initiative

Complete and return the forms to the NP SERT Program at the appropriate address below :

Ministry of Health and Long-Term Care
Primary Health Care
80 Queen Street, 3^rd Floor
Kingston ON K7K 6W7

We, the undersigned, agree that the Nurse Practitioner(s) that we employ will participate in the NP Service Encounter Reporting and Tracking Initiative and will submit new service encounter codes, identified as within the scope of his/her practice. The service encounter codes and patient information submitted by the Nurse Practitioners, or by the organization as an agent of the Nurse Practitioner, will be submitted through the Medical Claims Payment System in order for the Ministry of Health and Long-Term Care (MOHLTC) to determine or provide funding to the Nurse Practitioners for the provision of health care.

AGREED :

(Name of Organization)
(Group ID)
(Name of Organization's Lead)
(Signature of Organization's Lead)

(Date)

Nurse Practitioner(s) :

1. (Name)
RN (EC) Provider Number
Signature

(Effective Date)

2. (Name)
RN (EC) Provider Number
Signature

(Effective Date)

3. (Name)
RN (EC) Provider Number
Signature

(Effective Date)

4. (Name)
RN (EC) Provider Number
Signature

(Effective Date)

Additional Requirements : (forms to be completed by the Nurse Practitioner)

Interdisciplinary Health Provider - Undertaking by IHP for Participation in MRI (form no. 4752-84)
Interdisciplinary Health Provider - Electronic Data Transfer (EDT) Undertaking and Acknowledgement (form no. 4721-84)

Note :

The NP must wait for confirmation from the MOHLTC that he/she has been affiliated with the organization prior to submitting his/her services.
The NP must be approved for diskette/electronic submission prior to submitting his/her services.
The NP services must be submitted using his/her RN (EC) Billing Number (starts with 7# # # # #) and the organization's group billing number (starts with G# # #).
NP Services will be subject to normal OHIP processing rules and regulations (e.g. must have valid Health Number and Version Code, six month submission deadline, etc.).

The Ministry of Health and Long-Term Care's collection of the information on this form is necessary for the proper administration of the Primary Care Nurse Practitioner Program and Family Health Teams initiatives. The information will be used to assess, verify and monitor eligibility for payment and conduct program evaluations. For information about this collection, call 1 866 766-0266, in Toronto 416 325-3575, or write to the Director, Primary Health Care Branch, 80 Queen Street, 3rd Floor, Kingston ON K7K 6W7.