form submitted with claims to provide additional information regarding particular claim

form placed on top of bundles of primary care forms, to submit to ministry for processing.

Application to the Board to Amend the Conditions of, or Terminate the Appointment of a Representative under Subsection 27(7) or (8) of the Personal Health Information Protection Act.

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.

Eligibility Criteria for Trivalent Inactivated Influenza Vaccine.

he purpose of this form is to collect necessary information to obtain authorized consent and assure identity, under the Freedom of Information and Protection of Privacy Act (FIPPA), for application of services delivered by the Ministry of Health on your behalf (or for a “Health Care Group” in which you are a registered member), including: • Application for an OHIP Billing Number • Changes to Health Care Group Registration Information

Complete this voluntary aid (Clinician Aid C) if you have been asked by a “Medical Practitioner” or “Nurse Practitioner” to provide a written opinion confirming that the Patient meets the eligibility criteria to receive medical assistance in dying. You should also include the completed aid in the patient's medical records.

Application to the Board for a review of a finding of incapacity to manage property under subsection 20.2(1) of the Substitute Decisions Act

form to be completed by those eligible for eye exams to be covered under OHIP

Form completed by clients to record their wishes for organ/tissue donation

Form outlines the Conformance Testing-Acceptable Use Policy and is part of agreement between ministry and vendor who must successfully pass the conformance testing.

Used to apply for financial travel assistance by Northern Ontario residents who must travel long distances to access medical specialist services.

The withdrawal form is to be completed by individuals who have applied and paid to write the Ministry of Health (MOH) Advanced Emergency Medical Care Assistant (AEMCA) exam and now wish to withdraw from the exam.

Physicians complete form to apply for OHIP billing number and/or specialty billing number.

Form to request approval for patient to receive surgery In-Province.

form used for out-patient services incurred by visitors from another province

Emergency admission of a child to a secure treatment program.

Form authorizes the ministry to disclose an individual's personal claims history information directly to a third party.

For faster decisions, prescribers can use the SADIE online portal to submit requests to the Exceptional Access Program (EAP). Sign in through GO Secure (https://www.ebse.health.gov.on.ca) and select SADIE from the services drop-down menu. Visit the SADIE website for more information: http://www.ontario.ca/sadie. Alternatively, this form can be used for submitting requests to the EAP by fax.

The use of this aid is voluntary. It is being provided to assist you in making a written request for medical assistance in dying that complies with the legal requirements. Once you complete this request, you should provide it to your doctor or nurse practitioner. The completed aid may be included in your medical records and may be used by your doctor or nurse practitioner to provide health care to you.