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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.014-4793-67
Application for Funding - Respiratory Equipment & SuppliesUsed to apply for Funding for Respiratory Equipment & Supplies014-4823-67
Application for Funding Pressure Modification DevicesUsed to apply for Funding for Pressure Modification Devices014-3183-67
Application for Funding Limb ProsthesesUsed by Amputee Team, registered with ADP to request funding for conventional upper/lower limb prosthees.on00159
COVID-19 Vaccine Cold Chain Incident Exposure/Wastage ReportRecord and report COVID-19 cold chain failures by hospitals and long-term care homes to public health units and the ministry.014-3523-87
Ontario Drug Programs Enrollment Form014-0691-84
Request for Approval of Payment for Proposed SurgeryForm to request approval for patient to receive surgery out of Ontario014-2983-88
Confirmation of Payment Instruction014-3884-41
Review Findings014-3883-41
Program Funding Request014-3653-41
Dental Claim014-2002-41
Approval to Purchase Clothing014-3057-87
Nutrition ProductsUsed for obtaining authorization for nutrition products as an ODB benefit under certai circumstances014-4591-87
Request for Elaprase®To facilitate physician's in making an EAP request for funding/reimbursement of Elaprase for Hunter's Syndrome.