Government of Ontario: Ministry of Health

Primary Health Care

Request to Change Designated Physician - Group Enrolment

Microfilm use only

Please PRINT using black or blue ball point pen.

This form

• is only for use by primary health care groups who have opted for group enrolment and consent
• is only for changing the designated physician of individual patients
• must include the effective date of the change of designated physicians
• should be stamped and/or signed by both the current and new designated physicians
• should be submitted with your batch of Patient Enrolment and Consent to Release Personal Health Information forms

Each field marked by an asterisk ( * ) must be completed.

Section 1 – Patient Information

Health Number *
Date of Birth * (yyyy/mm/dd)

Last Name *
First Name *
Middle Name

Section 2 – Current Designated Physician Information

Last Name
First Name
Billing No.
Group No.
Physician Signature or Acknowledgement Stamp

Note: If you use your acknowledgement stamp the left side of Section 2 may be left blank.

Section 3 – New Designated Physician Information

Last Name
First Name
Billing No.
Group No.
Effective Date of Change of Designated Physician * (yyyy/mm/dd)
Physician Signature or Acknowledgement Stamp

Note: If you use your acknowledgement stamp the left side of Section 3 may be left blank, with the exception of the effective date.