-
014-1667-88
Application for Physician Locum Programs -
on00704
2025 Physician Assistant (PA) Career Start - Contact, Recruitment and Financial (CRF) FormThe form collects contact, recruitment and financial information from applicants who have successfully recruited PA graduates.014-4931-87
Annual Deductible Re-Assessment RequestThis form is available on the Ontario Drug Benefit Program Online Applications and Forms website : https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.014-4282-64
Prequalification Form for Organizations Requesting Publicly Funded Influenza Vaccine for the 2025/2026 Universal Influenza Immunization Program (UIIP)Prequalification form for health care agencies and workplaces that are required to prequalify in order to receive influenza vaccine.on00313
Request to End Household Enrolment in the Trillium Drug ProgramThis form is available on the Ontario Drug Benefit Program Online Applications and Forms website: https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.014-4930-87
Request to Remove a Household Member(s) from the Trillium Drug ProgramThis form is available on the Ontario Drug Benefit Program Online Applications and Forms website : https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.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 available014-3693-87
Trillium Drug Program ApplicationThe Trillium Drug Program Application is available on the Ontario Drug Benefit Program Online Applications and Forms website: https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.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.014-4929-87
Trillium Drug Program Application Signature RequestThis form is available on the Ontario Drug Benefit Program Online Applications and Forms website: https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.014-4423-87
Notification for Change of Information for Trillium Drug ProgramThis form is available on the Ontario Drug Benefit Program Online Applications and Forms website: https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.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 donation014-4777-87
Request for Zavesca® - Niemann Pick Type C (NPC)To facilitate prescribers making reimbursement claims for treatment of Niemann Pick Type C (NIPC).014-4747-84
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.014-4537-67
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 donation
