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014-4598-67
PAP Device Evaluation Form -
014-4917-67
Vendor Registration ApplicationThe Vendor Registration Application form is an interactive form that will be completed by an Ontario retailer or supplier of assistive devices who is requesting registration with the Assistive Devices Program. -
014-7158-84
In-Patient Standard Ward Costsform used for inpatients to Ontario hospitals who are here visiting from other provinces -
4969-47
Diabetes Education ChecklistThe MedsCheck for Diabetes includes an Annual review that involves using the pharmacist's worksheet and providing the patient with a MedsCheck Personal Medication Record; as well as using a Diabetes Education Checklist and providing the patient with a Diabetes Education Patient Take-Home Summary. -
4967-47
Pharmacists WorksheetMust be completed for every MedsCheck; pharmacists must have professional notes and/or a worksheet when conducting a MedsCheck. -
014-4509-67
Application for Equipment Listing Insulin PumpsUse by vendor/manufacturer to apply for equipment listing insulin pumps. -
014-0864-84
Authorization for Group PaymentForm completed by provider authorizing payment to go to group -
4974-47
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.
