This application is to be completed by health care professionals applying for an Ontario Health Insurance Plan (OHIP) billing number to submit claims to the Ministry of Health (the ministry) for insured services.
Monthly payments for your claim submissions will be issued electronically directly to your bank account. You must attach a scanned or original blank cheque with “VOID” written on it, from the financial institution where you bank, with the fully micro-encoded branch, institution and account numbers. A cheque is not required if you are a health professional joining a group(s) and you will only be providing services on behalf of the group.
Note: The ministry requires 30 days advance notice in writing, of any changes to your banking arrangements or practice address(es).
The ministry’s collection of the personal information on this form is authorized under the Health Insurance Act, R.S.O. 1990, c. H.6, section 4.1, and Ontario Regulation 57/97. The information will be used to register you as a provider and to verify and monitor your eligibility for payment. It will also be used for health planning and coordination purposes. For information about this collection, contact the Director, Health Data Branch, Health System Information Management and Investment Division, Ministry of Health, 5700 Yonge Street, 4th Floor, Toronto ON M2M 4K5, by telephone: 1-800-803-0104 toll free and in Kingsotn, 613-548-4049 or by email: iMsupport@ontario.ca.
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Surname Give Name(s) Date of birth (yyyy/mm/dd)
M F
No Yes Previous OHIP Billing Number
Type of Degree/Diploma University where health profession degree/diploma achieved Date of Degree/Diploma Received City Province/State Country
University / Institution City Province/State Country Discipline (specialty) Completion Date Date Certified
In order to obtain an OHIP billing number with the ministry, you must hold a valid licence with the governing body. If you hold an educational licence, you are not eligible to apply for an OHIP billing number at this time.
Indicate type of Current Certificate of Registration (e.g. Independent Practice, restriced) Effective Date of Current Certificate Current Registration Number issued by governing body
Indicate Country/Province of Certificate of Registration Type of Certificate Effective Date of Current Certificate Current Registration Number Current Registration Number issued by governing body
Ontario practice addresses (Note: PO box and R.R. numbers are not acceptable.) List any additional addresses on a separate piece of paper. Proof of your practice at the address may be required. Practice addresses are not considered personal information and may be disclosed upon request. As such, it is recommended that your residential addresses not be provided.
Mandatory Practice Address Reporting – Ontario Regulation 57/97 made under the Health Insurance Act requires that physicians provide, in writing, to the General Manager, an address for every place they regularly provide insured services to insured persons in Ontario. In addition to each address, it must be stated whether services are provided as a locum tenens and / or whether the only services provided are delegated procedures, as defined in the Schedule of Benefits, carried out under direct supervision of the physician. Provisions governing delegated procedures can be found in the General Preamble section of the Schedule of Benefits located at: http://www.health.gov.on.ca/english/providers/program/ohip/sob/physserv/genpre.pdf
Where multiple addresses exist, please identify, where possible, which one is the primary practice site. You must give the ministry at least 30 days advance notice of any changes to address information referred to above. Supporting documentation may be required to validate your address information provided.
Primary Practice Address – the site at which the majority of insured services is expected to be provided.
Additional Site Address – any additional site at which insured services are expected to be provided.
Private Practice Group Hospital Locum Delegated Service Other (e.g. employee)
Information Line (e.g. c/o name, department of, to the attention of, floor) Start Date (yyyy/mm/dd) Address (apt. / suite, street no. & name) City Province Country Postal Code Telephone Number Ext. Fax Number Email Address
Complete this secetion if you do not want your correspondence sent to the primary practice address.
Information Line (e.g. c/o name, department of, to the attention of, floor) Address (apt. / suite, street no. & name) City Province Country Postal Code Telephone Number Ext. Fax Number E-mail Address
I hereby authorize the ministry to make direct bank payment to my account. I have attached a scanned or original blank cheque with “VOID” written on it from the financial institution where I bank with the fully micro-encoded branch, institution and account numbers.
I declare the information provided to be true and I consent to allow the Ministry of Health to verify, with other sources, all information I have given in this application. These sources may include but not be limited to the Governing Body of my related Health Profession (e.g. College of Physicians and Surgeons of Ontario, College of Midwives of Ontario) and the medical school(s) and hospitals indicated in my application.
I understand that in applying for and subsequently receiving OHIP billing number(s) that I am subject to the provisions of the Health Insurance Act and Regulations under the Act. I am responsible to read and understand the information, but not limited to:
I understand that it is my responsibility to comply with the Health Insurance Act and Regulations under that Act, including, in the case of physicians, the Schedule of Benefits and that all claims must be submitted in accordance with that Act and Regulations thereunder. I acknowledge that only claims for services provided by me may be submitted under the OHIP billing number(s) assigned to me and that I am solely responsible for the veracity of those claims, regardless of who may prepare and/or submit claims for those services on my behalf and regardless of to whom payment is made.
It is a provincial offence to contravene the Health Insurance Act or any Regulations under that Act.
I understand that as a health information custodian I am required under the Personal Health Information Protection Act, 2004 to take steps that are reasonable in the circumstances to ensure that personal health information in my custody and control is protected against theft, loss and unauthorized use or disclosure and to ensure that the records containing that information are protected against unauthorized copying, modification or disposal.
I further understand that this obligation applies in connection with personal health information that I receive from or submit to the ministry in connection with OHIP billings.
Signature Date
For more information on completing this application and / or applying for an OHIP billing number, contact the ministry’s Service Support Contact Centre by email: SSContactCentre.MOH@ontario.ca or by calling 1-800-262-6524.