340 Forms found for 006-FORM-L

Ministries: Ministry of Health

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  • on00328
    Review of Emergency Admission to Secure Treatment Program

    This form is an order completed by the Chair of the Child and Family Services Review Board either releasing the child from the secure treatment program or denying the application.

  • 014-5035-64
    Healthy Smiles Ontario Parent Notification Preventive Services Only Stream (HSO-PSO)

    This form is to be used by Public Health Units after dental screening to notify parents/guardians that their child would benefit from preventive dental services. If the parent/guardian can complete the form and return it to the Public Health Unit if they wish to enroll their child into the Preventive Services Only Stream of Healthy Smiles Ontario.

  • on00334
    Clinician Aid D-1 - Waiver of Final Consent

    The use of this aid is voluntary. It is being provided to assist you in maintaining records for medical assistance in dying. Please use this aid if you are a “Medical Practitioner” or “Nurse Practitioner” and a patient is requesting a Waiver of Final Consent. The Waiver of Final Consent is ONLY applicable for individuals whose natural death is reasonably foreseeable (RFND).

  • 014-3889-22
    Clinician Aid A - Patient Request for Medical Assistance in Dying

    The use of this aid is voluntary. It is being provided to assist you in making a written request for medical assistance in dying that complies with the legal requirements. Once you complete this request, you should provide it to your doctor or nurse practitioner. The completed aid may be included in your medical records and may be used by your doctor or nurse practitioner to provide health care to you.

  • 014-4971-67
    Vendor Agreement

    The Ministry of Health and Long-Term Care's Assistive Devices Program provides customer centered support and funding to Ontario residents who have long-term physical disabilities to provide access to personalized assistive devices appropriate for the individual's basic needs. To accomplish this goal the ADP establishes contracts with vendors in order to ensure that ADP funding for clients are in accordance with Program policies.

  • on00461
    Applicant Report

    Form 2 - Applicant Report - Pursuant to the Mandatory Blood Testing Act, 2006 and O. Reg. 449/07 To support implementation of the Mandatory Blood Testing Act, 2006

  • on00460
    Physician Report

    Form 1 - Physician Report Pursuant to the Mandatory Blood Testing Act, 2006 and O. Reg. 449/07 To support implementation of the Mandatory Blood Testing Act, 2006

  • on00314
    Request for Prior Approval for Full Payment of Insured Out-of-Country (OOC) Health Services

    This form is meant to be submitted by a practicing Ontario physician on behalf of their patients to request consideration of funding for out-of-country health services. Along with the completed application form, submissions must also include relevant medical documentation.

  • 014-3224-67
    Application for Funding Hearing Devices

    Application used to determine eligibility for funding by ADP for Hearing Devices.

  • 014-3891-22
    Clinician Aid C - (Secondary) "Medical Practitioner" or "Nurse Practitioner" Medical Assistance in Dying Aid

    Complete this voluntary aid (Clinician Aid C) if you have been asked by a “Medical Practitioner” or “Nurse Practitioner” to provide a written opinion confirming that the Patient meets the eligibility criteria to receive medical assistance in dying. You should also include the completed aid in the patient's medical records.

  • 014-3296-64
    Non-Reusable Vaccine (spoiled or expired) Return Record - Toronto Clients

    Used by Toronto clients to return non-reusable vaccines (spoiled or expired) to the Ontario Government Pharmaceutical and Medical Supply Service

  • 014-3134-84
    Application For IVR Participation

    Provider/hospital applies for Interactive Voice Response to verify Health Card numbers via telephone

  • 014-1471-41
    Statement of Representative Appointed Under the Mental Health Act to Give or Refuse Consent on Patient's behalf to Access or Disclose Clinical Record

  • 014-4579-64
    Notice to Operate or Reopen a Small Drinking Water System

    The Small Drinking Water System Identification form is to be used by owners of small drinking water systems to notify in writing the medical officer of health in the health unit where their system is located before supplying drinking water to users of the system following construction or alteration of the small drinking water system or following a shut-down of the system that lasts longer than seven days.

  • on00700
    Laboratory Licensing and X-Ray Inspection Services Fees Payment

    To facilitate secure and real-time electronic payments for clinical laboratory licences and x-ray facility application fees using debit and credit cards.

  • 014-4817-69
    Long-Term Care Home Support Document List - Submitting NOA that included benefit(s) that a resident is no longer receiving because they have transitioned to new benefit(s)

    To be used by residents of LTC homes who would like to apply for a reduction in the amount of their basic accommodation fees. This document guides applicants in determining which supporting documents will be required as part of their application. This document is to be used by applicants who have a Notice of Assessment from the year when they were 64 years of age.

  • 014-4807-69
    Application for Reduction in Long-Term Care Home Basic Accommodation - Schedule C: Continuation of Previous Dependant Deduction

    To be used by residents of LTC homes who would like to apply for a reduction in the amount of their basic accommodation fees. This schedule should be used with one of the four main forms. An applicant should use this schedule if their LTC home has notified them that they are eligible for a “Continuation of Previous Dependant Deduction”.

  • on00502
    Laboratory Requisition

    Laboratory Requisition Pursuant to the Mandatory Blood Testing Act, 2006 and O. Reg. 449/07 To support implementation of the Mandatory Blood Testing Act, 2006

  • on00520
    Relocation Application (Fixed Site)

    Licensees of Integrated Community Health Services Centres (ICHSCs) must submit an application and obtain written approval from the Director of Integrated Community Health Services Centres prior to a centre’s relocation. For the purposes of this application, a “Fixed Site” centre is a licensed ICHSC where the Limitations and Conditions of the licence specify a single geographic location or address where specified services may be provided.

  • 014-0406-67
    Authorizer Agreement with the Assistive Devices Program

    The Ministry of Health and Long-Term Care's Assistive Devices Program provides customer centered support and funding to Ontario residents who have long-term physical disabilities to provide access to personalized assistive devices appropriate for the individual's basic needs. To accomplish this goal the ADP must establish relationships with health professionals in order to ensure that ADP clients are assessed for cost-effective devices that best suit their needs.