Government of Ontario: Ministry of Health and Long-Term Care Homes for Special Care

Funding Request (for Prescribed Drugs not Covered by Ontario Drug Benefit (ODB) Plan)

Instructions:

1. Complete information. Print clearly.
2. Fax or mail to HSC Field Office.

Resident Name

Resident RAN No.

Name and address of residential HSC

HSC Licence No.

Name of prescribed drug

Cost

Reason for drug used

Estimate monthly cost

Name of physician prescribing drug

Is there an appropriate substitute covered by ODB?

Please indicate if drug
discontinued/removed from ODB
never covered by ODB
Other(specify)

Local HSC Office

Signature of HSC Field staff

Date

Home for Spcial Care - Mental Health Program

Authorized by:

Date

Personal information collected in this form is necessary to the proper administration of the Homes for Special Care Act, R.S.O. 1990, c.H.12 and Regulation 636 R.R.O. 1990 as amended. The principal purpose of the collectionis to assist with assessment, treatment and program planning for the resident. FOr information about his collection, please contact the Homes for Speical Care Regional Officer through the Regional Offices - Hospitals, Long Term Care and Mental Health Services. For Central East, Cenral West and Toronto contact hte Central East office at 465 Davis Drive Newmarket, L3Y 8T2 (905)954-4690, for the South west, Central South and Central West contact the South West office at 231 Dundas St. London N6A 1H1, (519)675-7680, for the North and East regions contact the North office at 159 Cedar St. Sudbury P3E 6A5. (705)564-3130.

White/Blanc - Ministry file
Canary/Canair - Patient file

3651-41 (01/07)