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on00521
Exceptional Access Program (EAP) – Biosimilar Exemption RequestThis form is only to be used by prescribers to request an exemption for Ontario’s Biosimilar Switch Policy for a patient who HAS BEEN USING AN ORIGINATOR BIOLOGIC REIMBURSED THROUGH THE ONTARIO DRUG BENEFIT (ODB) PROGRAM previously authorized through the Exceptional Access Program and is unable to switch from an originator biologic or who is requesting to switch back to the originator following biosimilar switch.014-5069-87
Drug Benefit Claim Reversal FormUsed by pharmacies for submitting claims or reversals014-4420-84
Health Claim014-2784-87
Drug Benefit Claim Submission FormUsed by pharmacies for submitting claims014-6429-41
Form 3 - Certificate of Involuntary Admission014-6428-41
Form 2 - Order for Examination under Section 16014-3760-41
Form 45 - Community Treatment Order014-4931-87
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.on00704
2024 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.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.014-3693-87
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.
