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)

Patient’s last name on Health Card
First name
Initials
Medicare no. Date of expiry

Permanent mailing address

Municipality
Province/territory Postal Code

Date of birth yyyy mm dd

Sex M F

Name of parent / Guardian

Relationship to patient

Date of departure from home province/territory yyyy mm dd

Place where treated (province, territory)

Date of arrival yyyy mm dd

Is this a permanent move? Yes No

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

Reason for absence from home vacation study

Name of institution business other (specify)

B Declaration of Patient or Parent / Guardian of Patient or Parent / Guardian of Patient I hereby declare, conscientiously believing it to be true and knowing it to have the same effect as if it were made under oath and by virtue of the Canada Evidence Act, that the information given above is correct and that I am a beneficiary of the Medical Care Plan in the province / territory of

I request that payment be made: directly to the physician to patient/contract holder

Signature of patient (If other than patient, state relationship to patient)
Date
Telephone no. (home)
Telephone no. (work)

C To be completed by Physician (please type or print clearly) Physician’s name Initials

Address
Postal Code

Specialty certified non-certified

If Anaesthetist Surgical Assistant Psychiatrist

Provide duration of service Hrs. Min.

Name of referring physician Speciality

Services provide in Office Home Hospital out-patient Hospital in-patient

If hospital services, please provide:
Name of hospital
Address

Admission date yyyy mm dd

Discharge date yyyy mm dd

If claiming in-patient care, please indicate service dates

Service date(s) Year Month

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Procedure/Treatment Fee code Fee
Date of service yy mm dd Time
Procedure/Treatment Fee code Fee
Date of service yy mm dd Time
Procedure/Treatment Fee code Fee
Date of service yy mm dd Time
Procedure/Treatment Fee code Fee
Date of service yy mm dd Time
Procedure/Treatment Fee code Fee
Date of service yy mm dd Time

Diagnosis and other remarks

For Office Use Only

Claims involves:
Workers’ compensation automobile accident pensionable disability other third party

Pay physician – I accept the patient’s plan payment as payment in full Pay patient
Physician’s signature Date

Language of correspondence
English French

0000–80 (03/10)