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014-4930-87
Request to Remove a Household Member(s) from the Trillium Drug ProgramThis form is available on the Ontario Drug Benefit Program Online Applications and Forms website : https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.014-3296-64
Non-Reusable Vaccine (spoiled or expired) Return Record - Toronto ClientsUsed by Toronto clients to return non-reusable vaccines (spoiled or expired) to the Ontario Government Pharmaceutical and Medical Supply Service014-5034-64
Healthy Smiles Ontario Parent Notification Form (PNF) Emergency and Essential Services Stream (EESS)This form is to be used by Public Health Units after dental screening to notify parents/guardians that their child has an emergency and/or essential dental condition(s). Parents/Guardian will complete the form and return it to the Public Health Unit to let them know that the child has initiated treatment or to attest to financial hardship and enroll into the Emergency and Essential Services Stream of Healthy Smiles Ontario.5041-77
Request for Prior Approval for Funding of Sex-Reassignment SurgeryForm to be completed by providers on behalf of patients seeking prior approval for insured sex-reassignment surgery.014-4752-84
Undertaking by Interdisciplinary Health Providers (IHP) for Participation in Machine Readable Input (MRI)Form that Interdisciplinary Health Providers will complete and sign agreeing to conform to ministry's technical specifications for claims submission in MRI014-4589-64
Response to Adverse Drinking Water Quality Incidents - IssueThis form is completed by Public Health Boards when MOH site is down.014-4817-69
Long-Term Care Home Support Document List - Submitting NOA that included benefit(s) that a resident is no longer receiving because they have transitioned to new benefit(s)To be used by residents of LTC homes who would like to apply for a reduction in the amount of their basic accommodation fees. This document guides applicants in determining which supporting documents will be required as part of their application. This document is to be used by applicants who have a Notice of Assessment from the year when they were 64 years of age.014-4906-87
Fabry Disease Enzyme Replacement Therapy (Agalsidase) AssessmentApplication form for drug therapy for Fabry disease014-4907-87
Fabry Disease Enzyme Replacement Therapy (Agalsidase) RenewalRenewal form dor drug therapy for Fabry disease014-4406-87
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.014-4929-87
Trillium Drug Program Application Signature RequestThis form is available on the Ontario Drug Benefit Program Online Applications and Forms website: https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.014-4423-87
Notification for Change of Information for Trillium Drug ProgramThis form is available on the Ontario Drug Benefit Program Online Applications and Forms website: https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.014-3233-87
Seniors Co-Payment Program ApplicationThe Seniors Co-Payment Program Application is available on the Ontario Drug Benefit Program Online Applications and Forms website: https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the SCP at 416-503-4586 (Toronto area) or 1-888-405-0405 (outside Toronto) for a paper version of this form.014-3224-67
Application for Funding Hearing DevicesApplication used to determine eligibility for funding by ADP for Hearing Devices.014-4812-99
Application to Re-enter Postgraduate Medical TrainingThe Application Form collects information from applicants regarding their contact information, medical practice and education history.014-0000-80
Out of Province Claim for Physician ServicesUnder Interprovincial agreement, for travel within Canada, patients/physicians submit form to get reimbursed by applicable health plan.014-4344-64
Influenza Vaccine Order Form for the Universal Influenza Immunization ProgramEligibility Criteria for Trivalent Inactivated Influenza Vaccine.
