You may use this form if you have applied and are enrolled in the Ontario Seniors Dental Care Program and would like to change the information provided at the time of application. Through this form, you can update applicant information, contact information, marital status and/or spousal information, income declaration, or withdraw consent to disclose personal information and/or personal health information.
For faster decisions, prescribers can use the SADIE online portal to submit requests to the Exceptional Access Program (EAP). Sign in through GO Secure (
https://www.ebse.health.gov.on.ca) and select SADIE from the services drop-down menu. Visit the SADIE website for more information:
http://www.ontario.ca/sadie. Alternatively, this form can be used for submitting requests to the EAP by fax.
Prequalification form for health care agencies and workplaces that are required to prequalify in order to receive influenza vaccine.
Receive 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.
The 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.
Hospitals submit form to ministry to obtain Health Number of patient when number is not available
he purpose of this form is to collect necessary information to obtain authorized consent and assure identity, under the Freedom of Information and Protection of Privacy Act (FIPPA), for application of services delivered by the Ministry of Health on your behalf (or for a “Health Care Group” in which you are a registered member), including:
• Application for an OHIP Billing Number
• Changes to Health Care Group Registration Information
Used to apply for Funding for Pressure Modification Devices
Used to apply for Funding for Respiratory Equipment & Supplies
Used by Amputee Team, registered with ADP to request funding for conventional upper/lower limb prosthees.
This form is to be used by Public Health Units after dental screening to notify parents/guardians that their child has an emergency and/or essential dental condition(s). Parents/Guardian will complete the form and return it to the Public Health Unit to let them know that the child has initiated treatment or to attest to financial hardship and enroll into the Emergency and Essential Services Stream of Healthy Smiles Ontario.
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.
accompanied with form completed by clients to record their wishes for organ/tissue donation
