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

Instructions:

Consult the Operating Guidelines for Homes for Special Care (HSC) policy on accompanying an HSC Tenant to a medical or legal (court ordered) appointment. Claims will only be considered if in accordance with established guidelines.
1. HSC owner/operator or other person accompanying the Tenant to complete and sign form.
2. Submit form to local HSC office.
3. Local HSC office to submit completed and signed form to the Ministry local area office.

Tenant Name

Tenant RAN No.

HSC Licence No.

Name and address of the person/agency accompanying the HSC tenant, if different from the invoice summary.

Describe the destination and reason) for accompanying the HSC Tenant and the nature of medical/legal (court ordered)
appointment (i.e. visit to family physician or emergency hospital admission).

Date traveled(yyyy/mm/dd)

No. of km

Cost per km (0.40)

Km cost $ "A"

Date traveled(yyyy/mm/dd)

No. of km

Cost per km (0.40)

Km cost $ "A"

Date traveled(yyyy/mm/dd)

No. of km

Cost per km (0.40)

Km cost $ "A"

Date traveled(yyyy/mm/dd)

No. of km

Cost per km (0.40)

Km cost $ "A"

Sub total $

Travel and waiting time

Hourly rate $11.25

Hourly cost "B"

Travel and waiting time

Hourly rate $11.25

Hourly cost "B"

Travel and waiting time

Hourly rate $11.25

Hourly cost "B"

Travel and waiting time

Hourly rate $11.25

Hourly cost "B"

Sub total $

Total cost (add submit total "A" + "B")

This is to certify that above expenses were incurred by me while using my personally owned vehicle and the vehicle insurance permitted its use for this purpose.

Signature of claimant(operator or other invidual providing escort service)

Local HSC Office Use Only

Local HSC office

Signature of HSC field staff

Date