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014-5119-84
Consent Authorization Form: Disclosure of Personal Claims History (PCH) Information to Third PartyReceive information required to prove consent provided by individuals or individual's decision makers in order to process Personal Claims History information requests from Third Parties.4970-47
Diabetes Education Patient Take Home SummaryThe 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.014-1265-84
Health Number ReleaseHospitals submit form to ministry to obtain Health Number of patient when number is not available014-4521-84
Application for Prior Approval for Full Payment of Insured Out-of-Country (OOC) & Out-of-Province (OOP) Laboratory & Genetics TestingThe OOC/OOP PA Program eForm is designed to be completed and submitted electronically for application for prior approval for full payment of insured Out-of-Country (OOC) & Out-of-Province (OOP) laboratory and genetics testing services. English and French versions can be completed online or downloaded and saved for future use.014-4769-85
Appointment & Acknowledgement of Quality Assurance AdvisorThe ICHSC Program must be notified of a change in quality assurance advisor through the submission of the Quality Assurance Advisor form which must be signed by both the centre’s quality assurance advisor and the licensee.014-4871-64
User Agreement for Pharmacies with a Registered Injection-Trained Pharmacist Requesting Publicly Funded Influenza Vaccines for the 2025/2026 Universal Influenza Immunization Program (UIIP)User Agreement for Pharmacies Requesting Publicly Funded Influenza Vaccine in accordance with the UIIP Prequalification form for health care agencies and workplaces that are required to prequalify in order to receive influenza vaccine.014-4594-84
Fact Sheet - Gift of Life Consent Form - Organ and Tissue Donor Registrationaccompanied with form completed by clients to record their wishes for organ/tissue donation014-4747-84
Application for IHP Claims Submission and Remittance Advice in Machine Readable Input (MRI)IHPs requesting approval to submit their claims in MRI format014-5036-64
Healthy Smiles Ontario - Ontario Works First Nations Verification FormFirst Nations clients receiving Ontario Works will fill out this form and mail it to the HSO Program Administrator in order to enroll in the Healthy Smiles Ontario Program.014-4347-84
Request for Major Eye Examinationform to be completed by those eligible for eye exams to be covered under OHIP014-4537-67
Application for Funding Insulin Pumps and Supplies for AdultsApplication used to determine elegibility for funding by ADP for insulin pumps and supplies014-3750-84
Organ and Tissue Donor RegistrationForm completed by clients to record their wishes for organ/tissue donation014-4860-84
Vendor Application for Conformance Testing-Acceptable Use PolicyForm outlines the Conformance Testing-Acceptable Use Policy and is part of agreement between ministry and vendor who must successfully pass the conformance testing.014-2743-84
Request for Approval of Payment for Proposed Dental Proceduresform completed to obtain approval for dental procedures to be carried out in hospital and covered by OHIP014-4721-84
IHP Electronic Data Transfer (EDT) Undertaking and Acknowledgement for Nurse Practitioners (NP)Form used as part of EDT registration package for IHPs014-4750-84
Application for IHP GONet Electronic Data Transfer (EDT) ServiceIHPs apply to submit claim information via EDT4969-47
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.
