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014-3890-22
Clinician Aid B - (Primary) “Medical Practitioner” or “Nurse Practitioner” Medical Assistance in Dying AidThe use of this aid is voluntary. It is being provided to assist you in maintaining records of requests for medical assistance in dying. Please use this aid if you are a “Medical Practitioner” or “Nurse Practitioner” and a patient is requesting medical assistance in dying and it is your intention to provide medical assistance in dying to the patient. You should also include the completed aid in the patient's medical records.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.014-4446-67
Application for Funding Insulin Pumps and Supplies for ChildrenUsed by clients to request funding assistance for Insulin Pumps and Supplies for Children014-4574-64
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 disease014-2203-64
Toronto Clients Requisition for Biological Supplies (for use in M postal code areas only)Used by Toronto Clients to order Biological Supplies from Ontario Government Pharmaceutical and Medical Supply Service.014-4751-84
Interdisciplinary Health Provider (IHP) Nurse Practitioner (NP) Authorization for Participation in the NP Service Encounter Reporting and Tracking (SERT) InitiativeForm will be used for NPs to become affiliated with an organization and participate in the NP Service Encounter Tracking and Reporting (SERT) Initiative to receive funding from the MOHLTC56-4965
Grow Your Own Nurse Practitioner Initiative - ApplicationThe Grow Your Own Nurse Practitioner Initiative Application is the application health care organizations must complete to request participation in the Grow Your Own Nurse Practitioner Initiative.014-3134-84
Application For IVR ParticipationProvider/hospital applies for Interactive Voice Response to verify Health Card numbers via telephone014-06-5040
Long-Term Care Home Inspection Report RequestAll Long-Term Care Home (LTCH) Inspection reports are posted on the Long-Term Care Homes public website (http://publicreporting.ltchomes.net/en-ca/default.aspx), in English. To request an accessible version or a French version of an Inspection report for a specific LTCH, please complete this form and submit it to the Health Data Branch (HDB), Ministry of Health and Long-Term Care.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 format014-4819-67
Application for Funding Orthotic DevicesUsed by Canadian board -certified orthotists registered with ADP to request funding for custom -made orthoses014-4421-84
Reciprocal ClaimClaim card used by physicians to receive reimbursement for reciprocal claims4976-47
Healthcare Provider Notification of MedsCheck ServicesUsing 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.014-4885-84
Change of Address for Health Care Professionals014-4769-85
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.on00520
Relocation Application (Fixed Site)Licensees of Integrated Community Health Services Centres (ICHSCs) must submit an application and obtain written approval from the Director of Integrated Community Health Services Centres prior to a centre’s relocation. For the purposes of this application, a “Fixed Site” centre is a licensed ICHSC where the Limitations and Conditions of the licence specify a single geographic location or address where specified services may be provided.014-4816-69
Rate Reduction Application in Long-Term Care - Document List Required for Assessment of Resident without NOATo be used by residents of LTC homes who would like to apply for a reduction in the amount of their basic accommodation fees. This document guides applicants in determining which supporting documents will be required as part of their application. This document is to be used by applicants who do not have a Notice of Assessment.
