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 form if you wish to have the Ministry of Health and Long-Term Care reinstate your laboratory test information in the Ontario Laboratories Information System (OLIS) after your lab test has been completed.
You may use this application form to apply for the Ontario Seniors Dental Care Program if you do not have a valid Social Insurance Number (SIN) and/or if you have not filed your Personal Tax Return(s) with Canada Revenue Agency (CRA) for the most recent tax year. If you have a spouse (married or common law partner) who would also like to apply for the Program, they must complete their own application form.
You may use this form to authorize the program administrator of the Ontario Seniors Dental Care Program to deal with another person (such as your spouse or common-law partner, other family member, friend, or accountant) as your representative for program matters. The same form can be used to cancel a previously-made authorization.
Eligibility Criteria for Trivalent Inactivated Influenza Vaccine.
Application form completed by rehabilitation professionals applying to Underserviced Area Program for financial incentives, in return for filling full-time vacancies in MOHLTC fully-funded positions in Northern Ontario.
Used by Toronto Clients to order Biological Supplies from Ontario Government Pharmaceutical and Medical Supply Service.
Form to be completed by providers on behalf of patients seeking prior approval for insured sex-reassignment surgery.
Form used by physicians to make inquiries regarding payment details on Remittance Advice
This form is completed by Public Health Boards when MOH site is down.
Form allows providers to refer patients for assessment for the program and will be used by hospital sites to record patient eligibility.
Form that Interdisciplinary Health Providers will complete and sign agreeing to conform to ministry's technical specifications for claims submission in MRI
This form is completed by Public Health Boards when MOH site is down.
