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014-1948-95
Application for Direct Bank Payment - ADPUsed by clients/vendors to receive remuneration by direct deposit versus cheque.014-4574-64
Vaccine Cold Chain Maintenance Inspection ReportUsed by public health units when conducting cold chain maintenance inspections in premises that store publicly funded vaccines.014-4846-87
Request for Aldurazyme®To facilitate prescribers making reimbursement claims for treatment of Hurler-Scheie and Hurler disease014-1668-69
Application for a Licence to Establish or Maintain and Operate a Nursing HomeApplication for a Licence to Establish or Maintain and Operate a Nursing Home014-4750-84
Application for IHP GONet Electronic Data Transfer (EDT) ServiceIHPs apply to submit claim information via EDT014-4573-84
Primary Health Care Request to Change Designated Physician - Group EnrolmentUsed by primary care groups who have opted for group enrolment and consent and is only for changing the designated physician of individual patients.4969-47
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.4974-47
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.014-4896-64
Notice of Transfer from a School - Immunization of School Pupils ActNotice of Transfer from a School - Immunization of School Pupils Act014-4575-64
Vaccine Cold Chain Incident Exposure/Wastage ReportUsed by public health units to report vaccine cold chain incidents and wasted or exposed vaccine.014-0225-47
Funding Enrollment for E.S.R.D. PatientsTo register ESRD patients for Special Drug Program for provision of Eythropoietins.on00329
Warrant to Apprehend and Return a Child Who has Been Admitted to a Secure Treatment ProgramCourt Proceeding and to apprehend a child who has been admitted to a secure treatment program.014-4637-67
Application for Rehabilitation Assessor/Fitter/Dispenser StatusApplication for Rehabilitation Assessor/Fitter/Dispenser Status014-4591-87
Request for Elaprase®To facilitate physician's in making an EAP request for funding/reimbursement of Elaprase for Hunter's Syndrome.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.014-4900-85
Physician Affiliation Authorization and Declaration of Professional Standing for ICHSCsThe form is used to confirm a physician's qualifications to provide the requested services prior to processing a request to affiliate to a particular ICHSC. The licensee must ensure that the physician has been affiliated to the centre before they begin to provide licensed services.014-4897-64
Statement of Conscience or Religious Belief – Immunization of School Pupils ActA parent must complete a Statement of Conscience or Religious Belief and have it witnessed by a commissioner for taking affidavits if they wish to obtain a non-medical exemption for their child from vaccine requirements under the Immunization of School Pupils Act.014-4895-64
Statement of Medical Exemption – Immunization of School Pupils ActA physician or nurse practitioner must complete a Statement of Medical Exemption for children who require a medical exemption from vaccine requirements under the Immunization of School Pupils Act.
