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014-2862-69
Medical Certificate Form 3Application used by First Nations and the North014-4897-64
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.0327-88
Application for Northern Health Travel GrantUsed to apply for financial travel assistance by Northern Ontario residents who must travel long distances to access medical specialist services.014-4812-99
Application to Re-enter Postgraduate Medical TrainingThe Application Form collects information from applicants regarding their contact information, medical practice and education history.014-5095-87
Consent to the Ministry of Health Collection and/or Disclosure of Personal Health Information for Ontario Drug Benefit Program RecipientsThis 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.014-4928-87
Updating Private Insurance for 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.014-4929-87
Trillium Drug Program Application Signature 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.014-4423-87
Notification for Change of Information for 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.014-3889-84
Medical Liability Protection (MLP) Reimbursement Program Authorization/ Direct Deposit RequestPhysicians complete form to indicate their preference on how malpractice reimbursement will be sent to them.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.014-0951-84
Out-of-Province/Out-of-Country Claim SubmissionForm used so patient can submit out of country medical receipts014-0918-84
Remittance Advice InquiryForm used by physicians to make inquiries regarding payment details on Remittance Advice014-5056-87
Information Available to Health Care Providers through the Digital Health Drug Repository“The Digital Health Drug Repository (DHDR) Reference Guide may be used by health care providers to understand the inclusions and limitations of the information available through the DHDR.”014-4846-87
Request for Aldurazyme®To facilitate prescribers making reimbursement claims for treatment of Hurler-Scheie and Hurler disease014-4573-84
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.
