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on00029
Form Y5Application to the Board to Amend the Conditions of, or Terminate the Appointment of a Representative under Subsection 305(8) or (9) of the Child, Youth and Family Services Act.014-7158-84
In-Patient Standard Ward Costsform used for inpatients to Ontario hospitals who are here visiting from other provinces4974-47
Patient Take Home SummaryPharmacists may provide patients with a MedsCheck Patient Take-Home Summary that is intended to further engage patients in identifying ways to build added awareness in their drug therapy and help to identify therapy-related goals.4968-47
Personal Medication RecordUsing the standardized fax template, pharmacists must share the completed MedsCheck Personal Medication Record with the patient's primary prescriber. A record of the successfully transmitted fax must be kept on file at the pharmacy.014-4896-64
Notice of Transfer from a School - Immunization of School Pupils ActNotice of Transfer from a School - Immunization of School Pupils Act014-2404-84
Claims Flagged for Manual Reviewform submitted with claims to provide additional information regarding particular claim014-4575-64
Vaccine Cold Chain Incident Exposure/Wastage ReportUsed by public health units to report vaccine cold chain incidents and wasted or exposed vaccine.014-5068-39
Health and Well-Being Grant Program Statement of InterestStatement of Interest application form for the Health and Well-Being Grant Programon00314
Request for Prior Approval for Full Payment of Insured Out-of-Country (OOC) Health ServicesThis 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.
