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.
Form 3 - Respondent Report - Pursuant to the Mandatory Blood Testing Act, 2006 and O. Reg. 449/07
To support implementation of the Mandatory Blood Testing Act, 2006
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.
The Grow Your Own Nurse Practitioner Initiative Application is the application health care organizations must complete to request participation in the Grow Your Own Nurse Practitioner Initiative.
PPLBP forms gather necessary information to help determine the applicant eligibility for the program.
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.
Form authorizes the ministry to disclose an individual's personal claims history information directly to a third party.
Receive information required to process Personal Claims History information requests from individuals or individual's substitute decision makers.
The Notice of Adverse Test Results and Issue Resolution form is to be used by licensed laboratories and owners/operators of small drinking water systems to support required written notifications pertaining to small drinking water system adverse water quality incidents (AWQI).
This form is used by manufacturers/distributors of mobility equipment (wheelchairs and wheeled walkers) for the purpose of making application to the Assistive Devices Program requesting approval to list their respective products on the list of approved devices.
Record and report COVID-19 cold chain failures by hospitals and long-term care homes to public health units and the ministry.
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.
