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014-5119-84
Consent Authorization Form: Disclosure of Personal Claims History (PCH) Information to Third PartyReceive information required to prove consent provided by individuals or individual's decision makers in order to process Personal Claims History information requests from Third Parties.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 Service014-3437-67
Application for Funding of Changes/Modifications/New Options to ADP Approved DevicesThis 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.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 MOHLTC014-3134-84
Application For IVR ParticipationProvider/hospital applies for Interactive Voice Response to verify Health Card numbers via telephone014-1819-67
Application for Equipment Listing Wheelchairs, Positioning and Ambulation AidsThis 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.014-4578-64
Laboratory Services Notification (LSN)The Laboratory Services Notification (LSN) form is to be used by small drinking water system owners/operators to notify the local public health unit in writing as to which licensed laboratories will test drinking water samples for their small drinking water systems.014-5036-64
Healthy Smiles Ontario - Ontario Works First Nations Verification FormFirst Nations clients receiving Ontario Works will fill out this form and mail it to the HSO Program Administrator in order to enroll in the Healthy Smiles Ontario Program.014-4815-69
Rate Reduction Application in Long-Term Care - Document List Required for Assessment of Resident EligibilityTo 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.5128
Ontario Seniors Dental Care Program. Change of InformationYou may use this form if you have applied and are enrolled in the Ontario Seniors Dental Care Program and would like to change the information provided at the time of application. Through this form, you can update applicant information, contact information, marital status and/or spousal information, income declaration, or withdraw consent to disclose personal information and/or personal health information.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.014-0406-67
Authorizer Agreement with the Assistive Devices ProgramThe Ministry of Health and Long-Term Care's Assistive Devices Program provides customer centered support and funding to Ontario residents who have long-term physical disabilities to provide access to personalized assistive devices appropriate for the individual's basic needs. To accomplish this goal the ADP must establish relationships with health professionals in order to ensure that ADP clients are assessed for cost-effective devices that best suit their needs.on00461
Applicant ReportForm 2 - Applicant Report - Pursuant to the Mandatory Blood Testing Act, 2006 and O. Reg. 449/07 To support implementation of the Mandatory Blood Testing Act, 2006on00574
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 Portal014-4807-69
Application for Reduction in Long-Term Care Home Basic Accommodation - Schedule C: Continuation of Previous Dependant DeductionTo be used by residents of LTC homes who would like to apply for a reduction in the amount of their basic accommodation fees. This schedule should be used with one of the four main forms. An applicant should use this schedule if their LTC home has notified them that they are eligible for a “Continuation of Previous Dependant Deduction”.014-4579-64
Notice to Operate or Reopen a Small Drinking Water SystemThe Small Drinking Water System Identification form is to be used by owners of small drinking water systems to notify in writing the medical officer of health in the health unit where their system is located before supplying drinking water to users of the system following construction or alteration of the small drinking water system or following a shut-down of the system that lasts longer than seven days.014-4872-88
Application for Northern Physician Retention InitiativeApplication form completed by physicians to apply to Northern Physician Retention Initiative for financial incentives.
