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014-3883-41
Program Funding Request -
014-2002-41
Approval to Purchase Clothing -
on00700
Laboratory Licensing and X-Ray Inspection Services Fees PaymentTo facilitate secure and real-time electronic payments for clinical laboratory licences and x-ray facility application fees using debit and credit cards.014-4406-87
Request for an Unlisted Drug Product - Exceptional Access Program (EAP)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.on00574
Provider Registration/Change Request FormThis application is to enable currently licensed health care professionals to be able to begin submitting or continue to submit claims to the Ministry of Health (the ministry) for insured services. Options include: • Register for an OHIP Billing Number • Register a Health Care Group • Authorize the ministry to make payments to a health care group on your behalf • Update address, banking, and/or group information • Register for Interactive Voice Response (IVR) • Register for the SAV Portal014-4900-85
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.014-4751-84
Interdisciplinary Health Provider (IHP) Nurse Practitioner (NP) Authorization for Participation in the NP Service Encounter Reporting and Tracking (SERT) InitiativeForm will be used for NPs to become affiliated with an organization and participate in the NP Service Encounter Tracking and Reporting (SERT) Initiative to receive funding from the MOHLTC014-2045-67
Release of Information About Previous FundingWritten consent to release information enables the Assistive Devices Program to provide a history of previously funded equipment/supplies to a client and/or third party as specified.014-4747-84
Application for IHP Claims Submission and Remittance Advice in Machine Readable Input (MRI)IHPs requesting approval to submit their claims in MRI format014-1057-82
(Change of Address form) What's Your Address?Form used to update/change address information of OHIP cardholders014-4591-87
Request for Elaprase®To facilitate physician's in making an EAP request for funding/reimbursement of Elaprase for Hunter's Syndrome.014-7026-65
Health Service Organization Information Sheet014-3056-64
Daily Record of Spa Operation014-1667-88
Application for Physician Locum Programs014-1470-41
Memorandum of Transfer – NCR Patient014-0265-82
Registration for Ontario Health CoverageForm is used to register new or returning Ontario residents or renew photo Health Card and contains instructions/information.014-4340-84
Primary Care - Time and Location of After Hours ServicesForm used to record hours of physicians in after hours clinics014-7158-84
In-Patient Standard Ward Costsform used for inpatients to Ontario hospitals who are here visiting from other provinces
