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

Interdisciplinary Health Provider (IHP) Group Registration

We, the undersigned, currently licensed to practice in the Province of Ontario request designation as a Group to be known as :

Group Name

Effective Date of the Group for services on or after year
month
day

The name entered above will appear on the cheque and remittance advice, subject to approval by the Ministry of Health and Long-Term Care (MOHLTC).

Group Address Street No.
Street Name
Suite
City
Province
Postal Code

We understand that only one remittance advice per month will be issued payable to the above named Group as registered. We further understand that the MOHLTC registration number of the Provider providing services must appear on each submitted claim. This document serves as the MOHLTC's authorization to make payment to the Group for services rendered by the Providers listed below.

Providers to be registered with the Group

1. Name
Provider Number
License No.
Signatures Must be signed by each provider personally

2. Name
Provider Number
License No.
Signatures Must be signed by each provider personally

3. Name
Provider Number
License No.
Signatures Must be signed by each provider personally

4. Name
Provider Number
License No.
Signatures Must be signed by each provider personally

5. Name
Provider Number
License No.
Signatures Must be signed by each provider personally

6. Name
Provider Number
License No.
Signatures Must be signed by each provider personally

7. Name
Provider Number
License No.
Signatures Must be signed by each provider personally

8. Name
Provider Number
License No.
Signatures Must be signed by each provider personally

9. Name
Provider Number
License No.
Signatures Must be signed by each provider personally

10. Name
Provider Number
License No.
Signatures Must be signed by each provider personally

11. Name
Provider Number
License No.
Signatures Must be signed by each provider personally

12. Name
Provider Number
License No.
Signatures Must be signed by each provider personally

13. Name
Provider Number
License No.
Signatures Must be signed by each provider personally

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.

Notify the MOHLTC of any changes in the above information.

Return this form to your local MOHLTC office.