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014-4638-67
Authorizer Application - Attachment BAuthorizer Application - Attachment B014-1782-53
Form 1 - X-ray Equipment Registration014-0403-67
Application for Authorizer StatusApplication for Authorizer Status014-4598-67
PAP Device Evaluation Formon00817
Northern Health Travel Grant Application Online formOnline application form used to apply for financial travel assistance by Northern Ontario residents who must travel long distances to access medical specialist services.014-4832-84
Primary Health Care Enrolment Material Order FormPhysicians utilise form to order Primary Health Care select forms/materials from vendor.014-4500-69
Determination of Available Monthly Income Form 4Used for the determination of applicant's available monthly income.on00329
Warrant to Apprehend and Return a Child Who has Been Admitted to a Secure Treatment ProgramCourt Proceeding and to apprehend a child who has been admitted to a secure treatment program.on00334
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).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.014-0691-84
Request for Approval of Payment for Proposed SurgeryForm to request approval for patient to receive surgery In-Province.on00323
Application for Funding Real-Time Continuous Glucose Monitoring System (rtCGM)Used to apply for Funding Continuous Glucose Monitors (CGM) Supplies014-4446-67
Application for Funding Insulin Pumps and Supplies for ChildrenUsed by clients to request funding assistance for Insulin Pumps and Supplies for Children014-3750-84
Organ and Tissue Donor RegistrationForm completed by clients to record their wishes for organ/tissue donation014-4846-87
Request for Aldurazyme®To facilitate prescribers making reimbursement claims for treatment of Hurler-Scheie and Hurler disease014-3266-54
Application for Reduction of Assessed Co-payment FeesThis form is to be used for a patient who is seeking a reduction to the co-payment or for whom a reduction is sought further to the factors set out in section 10 of Reg. 552 under the Health Insurance Act.014-4342-84
Primary Care-List of Locations Where Group Serv. are Regularly ProvidedForm to show all group locations where physician services provided
