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014-4638-67
Authorizer Application - Attachment BAuthorizer Application - Attachment B014-5024-41
Form 4A - Certificate of Continuation014-0403-67
Application for Authorizer StatusApplication for Authorizer Statuson00856
Northern Health Travel Grant Patient Consent for Third-Party Agency RequestThe purpose of this form is for a patient to provide their consent to disclose Personal Health Information to a an NHTG program-approved Third-Party Agency and agree to direct the ministry to pay the entirety of the eligible Northern Health Travel Grant amount to the approved Third-Party Agency listed in the form.014-4895-64
Statement of Medical Exemption – Immunization of School Pupils ActA physician or nurse practitioner must complete a Statement of Medical Exemption for children who require a medical exemption from vaccine requirements under the Immunization of School Pupils Act.0327-88
Application for Northern Health Travel GrantUsed to apply for financial travel assistance by Northern Ontario residents who must travel long distances to access medical specialist services.014-3889-84
Medical Liability Protection (MLP) Reimbursement Program Authorization/ Direct Deposit RequestPhysicians complete form to indicate their preference on how malpractice reimbursement will be sent to them.014-2352-88
Application for Rehabilitation Incentive GrantApplication 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.014-4590-64
Response to Adverse Drinking Water Quality Incidents - ResolveThis form is completed by Public Health Boards when MOH site is down.014-4882-83
Oral and Maxillofacial Rehabilitation Program (OMRP) ApplicationForm allows providers to refer patients for assessment for the program and will be used by hospital sites to record patient eligibility.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 Service014-4777-87
Request for Zavesca® - Niemann Pick Type C (NPC)To facilitate prescribers making reimbursement claims for treatment of Niemann Pick Type C (NIPC).014-3750-84
Organ and Tissue Donor RegistrationForm completed by clients to record their wishes for organ/tissue donation4969-47
Diabetes Education ChecklistThe MedsCheck for Diabetes includes an Annual review that involves using the pharmacist's worksheet and providing the patient with a MedsCheck Personal Medication Record; as well as using a Diabetes Education Checklist and providing the patient with a Diabetes Education Patient Take-Home Summary.014-4821-67
Application for Funding Maxillofacial Extraoral ProsthesesFor Specialist physician & ADP registered authorizers to request funding for extraoral (facial) prostheses.014-4820-67
Application for Funding Maxillofacial Intraoral ProsthesesFor Specialist physician & ADP registered authorizer to request funding for intraoral (mouth) prostheses.014-4392-67
Application for Funding Breast Prosthesis GrantUsed by clients to apply for funding for a silicone breast prosthesis(es)014-2860-69
Application for Reimbursement by The ProvinceApplication used by Homemaker and Nurses to request reimbursement from the Province for services provided.014-4792-67
Application for Funding Ventilator Equipment and SuppliesUsed to apply for Funding for Ventilator Equipment and Supplies
