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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 provinces4974-47
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.014-2404-84
Claims Flagged for Manual Reviewform submitted with claims to provide additional information regarding particular claim014-4575-64
Vaccine Cold Chain Incident Exposure/Wastage ReportUsed by public health units to report vaccine cold chain incidents and wasted or exposed vaccine.014-5068-39
Health and Well-Being Grant Program Statement of InterestStatement of Interest application form for the Health and Well-Being Grant Program014-5033-64
Healthy Smiles Ontario Emergency and Essential Services Stream (HSO-EESS) Application FormThis form is to be used by fee-for-service dental providers to enroll clients into the Emergency and Essential Services Stream of Healthy Smiles Ontario.014-4871-64
User Agreement for Pharmacies with a Licensed Injection-Trained Pharmacist Requesting Publicly Funded Influenza Vaccines for the 2024/2025 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.014-4282-64
Prequalification Form for Organizations Requesting Publicly Funded Influenza Vaccine for the 2024/2025 Universal Influenza Immunization Program (UIIP)Prequalification form for health care agencies and workplaces that are required to prequalify in order to receive influenza vaccine.on00703
2024 Physician Assistant (PA) Career Start Grant Application FormThe Application form collects information from employers to determine their eligibility for funding through the PA Career Start Program.on00347
Request for Disclosure of Personal Claims History (PCH) Information to a Third Party (for High-Volume Submitters)The eForm is currently unavailable at this time. We would like to have the option to re-activate the eForm at a later date.014-4918-57
Request for Rights Advice Mental Health InpatientUsed by Mental Health Inpatient Unit staff to request Rights Advice. Form is completed when a physician issues a Mental Health Act form that requires the provision of Rights Advice. Fax form to the PPAO and Rights Adviser will be assigned014-4594-84
Fact Sheet - Gift of Life Consent Form - Organ and Tissue Donor Registrationaccompanied with form completed by clients to record their wishes for organ/tissue donation014-5050-67
Vendor Registration Application - Home Oxygen TherapyThe Vendor Registration Application form is an interactive form that will be completed by an Ontario retailer or supplier of home oxygen therapy who is requesting registration with the Assistive Devices Program.7219-41
Form 17 - Notice to the Board of the Need to Schedule a Mandatory Review of a Patient's Involuntary Status under Subsection 39(4) of the ActNotice to the Board of the Need to Schedule a Mandatory Review of a Patient's Involuntary Status under Subsection 39(4) of the Act
