Collection of personal information as described on this form is for the determination of eligibility for health coverage, determination of fees payable, health planning and co-ordination and administration of the Health Insurance Act. RSO 1990, cH6.,subsections4.1(1) and (2) and subsection 17.1(3). The information collected may be verified by comparing it with information collected from other government and non-government organizations where permitted by law. For information about collection practices call the Director, Provider Services Branch at 49 Place d'Armes, 2nd Floor, Kingston ON K7L 5J3, (613) 548-6716. This notice is given in accordance with subsection 39(2) of the Freedom of Information and Protection of Privacy Act.
Physician name (print) Physician Billing Number Month Year Patient name (print) Health Number and Version Original CTO issuance date
Provide time in minutes for each of the specific elements - see schedule for details. Elapsed time is rounded to nearest minute.
Physician signature
Date
Total minutes
Divide by 30
Total units
1. A separate CTO Report Log must be completed: for each calendar month by each physician directly involved in CTO services for each patient for each of the three applicable fee codes (K887, K888, K889)
2. The completed CTO Report Log must accompany your claims submission.
3. A CTO must be renewed every six months.
4. See General Preamble for definitions and time-keeping requirements. For audit purposes the details of each activity must be recorded in the patient permanent medical record. The CTO Report Log by itself is insufficient for audit purposes.
5. The elapsed time for each individual activity is recorded separately rounded to the nearest minute.
6. The total number of 1/2 hour units are calculated by adding the total number of minutes for the month, dividing by 30 and rounding to the nearest whole unit.
Example: Total monthly minutes: 55 Divide by 30: 1.83 Total units: 2
3759-83 (00/12)