form used so physicians can have direct deposit of payment of claims

Form that Interdisciplinary Health Providers will complete and sign agreeing to conform to ministry's technical specifications for claims submission in MRI

This form is completed by Public Health Boards when MOH site is down.

form used for inpatients to Ontario hospitals who are here visiting from other provinces

Pharmacists 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.

form submitted with claims to provide additional information regarding particular claim

Used by public health units to report vaccine cold chain incidents and wasted or exposed vaccine.

To provide patient advocacy groups with a template for written submissions to the ministry on a drug; the form is to make sure all the appropriate information is provided.

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.

Written consent to release information enables the Assistive Devices Program to provide a history of previously funded equipment/supplies to a client and/or third party as specified.

The form collects contact, recruitment and financial information from applicants who have successfully recruited PA graduates.

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.

Form to show all group locations where physician services provided

Calculation of Chronic Care Co-Payments for use by hospital staff, patients, and families.

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.

The Application form collects information from employers to determine their eligibility for funding through the PA Career Start Program.

PPLBP forms gather necessary information to help determine the applicant eligibility for the program.

The eForm is currently unavailable at this time. We would like to have the option to re-activate the eForm at a later date.

Healthy Smiles Ontario Change of Information form is a paper form submitted by mail as a result of a change during any benefit year. This form is used to add or change information about the applicant, marital status and/or spouse, and children/youth. This form is only required for those who have applied and been enrolled in the core services stream of the program.

To help physicians to submit requests for drug funding for their ODB-eligible patients under the Compassionate Review Policy.