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

Primary Care
List of Locations Where Group Services are Regularly Provided

Please fax or mail the completed form to your designated ministry staff contact person.

In order to determine the geographic area for your group, the ministry requires a complete list of all locations where group services are regularly provided.

The geographic area is used for the purposes of determining patient geographic eligibility for enrolment in your group. The ministry uses the
group’s address locations that you provide to determine postal codes as the measure of residency within the 100–kilometre radius.

Please list all locations where group services are regularly provided, including:
– Physician offices.
– Extended hours office locations (if different than physician offices).
– Emergency departments (if extended hours and/or on-call services are provided at these locations).

Ministry Contact Information

Name
Fax Number
Date (yyyy/mm/dd)

Group Information

Group Name
Group Registration Number (FXXX)
Group Fax Number

For each location provide a complete address, including the postal code.
Street Address	City/Town	Postal Code
1. Street Address	City/Town	Postal code
2. Street Address	City/Town	Postal code
3. Street Address	City/Town	Postal code
4. Street Address	City/Town	Postal code
5. Street Address	City/Town	Postal code
6. Street Address	City/Town	Postal code
7. Street Address	City/Town	Postal code
8. Street Address	CityTown	Postal code
9. Street Address	City/Town	Postal code
10. Street Address	City/Town	Postal code
11. Street Address	City/Town	Postal code
12. Street Address	city/town	Postal code

This is a complete list of all locations where services are currently provided in our group. I am aware that I am responsible for drawing to my staff contact person’s attention any changes in locations where group services are routinely offered.

Physician Name (please print)

Signature Date (yyyy/mm/dd)

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

Primary Care List of Locations Where Group Services are Regularly Provided

Primary Care
List of Locations Where Group Services are Regularly Provided