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on00521
Exceptional Access Program (EAP) – Biosimilar Exemption RequestThis form is only to be used by prescribers to request an exemption for Ontario’s Biosimilar Switch Policy for a patient who HAS BEEN USING AN ORIGINATOR BIOLOGIC REIMBURSED THROUGH THE ONTARIO DRUG BENEFIT (ODB) PROGRAM previously authorized through the Exceptional Access Program and is unable to switch from an originator biologic or who is requesting to switch back to the originator following biosimilar switch.014-5035-64
Healthy Smiles Ontario Parent Notification Preventive Services Only Stream (HSO-PSO)This form is to be used by Public Health Units after dental screening to notify parents/guardians that their child would benefit from preventive dental services. If the parent/guardian can complete the form and return it to the Public Health Unit if they wish to enroll their child into the Preventive Services Only Stream of Healthy Smiles Ontario.014-4340-84
Primary Care - Time and Location of After Hours ServicesForm used to record hours of physicians in after hours clinics014-2404-84
Claims Flagged for Manual Reviewform submitted with claims to provide additional information regarding particular claim014-3891-22
Clinician Aid C - (Secondary) "Medical Practitioner" or "Nurse Practitioner" Medical Assistance in Dying AidComplete 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.56-4965
Grow Your Own Nurse Practitioner Initiative - ApplicationThe 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.014-4891-84
Request for Disclosure of Personal Claims History Information to a Third PartyForm authorizes the ministry to disclose an individual's personal claims history information directly to a third party.on00384
Clinician Aid D-2 – Advance Consent – Self-AdministrationThe use of this aid is voluntary. It is being provided to assist you in maintaining records for medical assistance in dying. Please use this aid if you are a “Medical Practitioner” or “Nurse Practitioner” and a patient is requesting Advance Consent for MAID Self-Administration.014-4316-84
Patient Enrolment Batch Headerform placed on top of bundles of primary care forms, to submit to ministry for processing.014-4819-67
Application for Funding Orthotic DevicesUsed by Canadian board -certified orthotists registered with ADP to request funding for custom -made orthoseson00421
Real-time Continuous Glucose Monitor RenewalUsed to renew funding for rtCGM014-4638-67
Authorizer Application - Attachment BAuthorizer Application - Attachment B014-0403-67
Application for Authorizer StatusApplication for Authorizer Statuson00334
Clinician Aid D-1 - Waiver of Final ConsentThe use of this aid is voluntary. It is being provided to assist you in maintaining records for medical assistance in dying. Please use this aid if you are a “Medical Practitioner” or “Nurse Practitioner” and a patient is requesting a Waiver of Final Consent. The Waiver of Final Consent is ONLY applicable for individuals whose natural death is reasonably foreseeable (RFND).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 format014-4919-57
Request for Rights Advice Community Treatment Order (CTO)Used by Mental Health Professional to request Rights Advice for both patient and SDM (if indicated). Form completed when Community Treatment Plan (CTP) and Form 49 are issued by physician. Form, CTP and Form 49 faxed to PPAO.014-4637-67
Application for Rehabilitation Assessor/Fitter/Dispenser StatusApplication for Rehabilitation Assessor/Fitter/Dispenser Status
