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014-5024-41
Form 4A - Certificate of Continuation -
014-1782-53
Form 1 - X-ray Equipment Registration -
014-0403-67
Application for Authorizer StatusApplication for Authorizer Status014-4598-67
PAP Device Evaluation Form014-3523-87
Ontario Drug Programs Enrollment Form014-0691-84
Request for Approval of Payment for Proposed SurgeryForm to request approval for patient to receive surgery In-Province.on00323
Application for Funding Real-Time Continuous Glucose Monitoring System (rtCGM)Used to apply for Funding Continuous Glucose Monitors (CGM) Supplies014-4446-67
Application for Funding Insulin Pumps and Supplies for ChildrenUsed by clients to request funding assistance for Insulin Pumps and Supplies for Children014-1945-67
Application for Funding Ostomy GrantThe information on this form is used to determine eligibility for grant assistance under the Assistive Devices Program.014-3750-84
Organ and Tissue Donor RegistrationForm completed by clients to record their wishes for organ/tissue donation014-4846-87
Request for Aldurazyme®To facilitate prescribers making reimbursement claims for treatment of Hurler-Scheie and Hurler disease014-3266-54
Application for Reduction of Assessed Co-payment FeesThis form is to be used for a patient who is seeking a reduction to the co-payment or for whom a reduction is sought further to the factors set out in section 10 of Reg. 552 under the Health Insurance Act.014-4342-84
Primary Care-List of Locations Where Group Serv. are Regularly ProvidedForm to show all group locations where physician services provided4969-47
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.014-0280-82
Change of InformationForm used to change status of OHIP coverage - i.e., change of address, name, citizenship status, etc. or to cancel OHIP coverage or replacement of lost, stolen and damaged card
