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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.014-0951-84
Out-of-Province/Out-of-Country Claim SubmissionForm used so patient can submit out of country medical receipts014-5056-87
Information Available to Health Care Providers through the Digital Health Drug Repository“The Digital Health Drug Repository (DHDR) Reference Guide may be used by health care providers to understand the inclusions and limitations of the information available through the DHDR.”014-4744-84
IHP Application for Direct Bank PaymentForm used by IHPs to set up direct bank deposit014-4573-84
Primary Health Care Request to Change Designated Physician - Group EnrolmentUsed by primary care groups who have opted for group enrolment and consent and is only for changing the designated physician of individual patients.on00326
Emergency Admission to Secure Treatment ProgramThis form is completed by the person in charge of the secure treatment program once the criteria are met for the child's emergency admission to a secure treatment program.014-7698-84
Application for OHIP Direct Bank Payment for Health Care Professionalsform used so physicians can have direct deposit of payment of claims014-4752-84
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.014-7158-84
In-Patient Standard Ward Costsform used for inpatients to Ontario hospitals who are here visiting from other provinces4974-47
Patient Take Home SummaryPharmacists may provide patients with a MedsCheck Patient Take-Home Summary that is intended to further engage patients in identifying ways to build added awareness in their drug therapy and help to identify therapy-related goals.014-2404-84
Claims Flagged for Manual Reviewform submitted with claims to provide additional information regarding particular claim014-4575-64
Vaccine Cold Chain Incident Exposure/Wastage ReportUsed by public health units to report vaccine cold chain incidents and wasted or exposed vaccine.014-4717-87
Submission of Patient EvidenceTo provide patient advocacy groups with a template for written submissions to the ministry on a drug; the form is to make sure all the appropriate information is provided.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.014-2045-67
Release of Information About Previous FundingWritten consent to release information enables the Assistive Devices Program to provide a history of previously funded equipment/supplies to a client and/or third party as specified.on00704
2024 Physician Assistant (PA) Career Start- CONTACT, RECRUITMENT AND FINANCIAL (CRF) FORMThe form collects contact, recruitment and financial information from applicants who have successfully recruited PA graduates.
