English - 4985-87e - Respiratory Syncytial...
To facilitate healthcare providers in making a Special Clinical Circumstance request for palivizumab funding.
Additional Information
| Last updated | November 23, 2022 |
|---|---|
| Created | December 11, 2021 |
| Format | application/pdf |
| Form Number | https://forms.mgcs.gov.on.ca/dataset/dd9a61fa-34a2-4f51-916b-d4293a66a397/resource/37344953-658e-4f1d-9ee1-705e451c28cd/download/4985-87e.pdf |
| Form File Identifier | 014-4985-87e |
| Name | English - 4985-87e - Respiratory Syncytial Virus (RSV) Prophylaxis for High-Risk Infants Program Enrolment - Special Clinical Circumstance Medical Justification Form |
| Form File Status | Available |
| Description | To facilitate healthcare providers in making a Special Clinical Circumstance request for palivizumab funding. |
| Language | English |
| Functionality | Fill and Print |
| Form File Content Type | Form |
| Remark | |
| Edition Date | 2022-11 |