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

Out of Province Claim for Physician Services

A To be completed by the Patient or Parent / Guardian of Patient (please type or print clearly)





Date of birth

Sex

Date of departure from home province/territory

Date of arrival

Is this a permanent move?

If no, specify date of return to home province/territory

Reason for absence from home

B Declaration of Patient or Parent / Guardian of Patient or Parent / Guardian of Patient
I request that payment be made:




C To be completed by Physician (please type or print clearly)


If

Provide duration of service

Services provide in



Admission date

Discharge date


Service date(s)


Service date(s)
















Claims involves:




0000–80 (03/10)