This form is to be completed by a Specialty-Service Provider who provides an OHIP-insured service to a patient who is eligible for a Northern Health Travel Grant (NHTG).
IMPORTANT: This form is to be used only for the purpose of patients looking to submit NHTG applications via the NHTG Online Form. This form must be included as an attachment and submitted via the NHTG Online Form, which you can access at the following location:
https://forms.mgcs.gov.on.ca/dataset/on00817
If you wish to submit by mail, please complete the NHTG Application available on the ministry website:
https://forms.mgcs.gov.on.ca/dataset/0327-88
Used to evaluate Insulin pumps
Used to apply for Funding for Ocular Prostheses
Use by vendor/manufacturer to apply for equipment listing insulin pumps.
Form used to update/change address information of OHIP cardholders
Used by pharmacies for submitting claims or reversals
Used by pharmacies for submitting claims
