he purpose of this form is to collect necessary information to obtain authorized consent and assure identity, under the Freedom of Information and Protection of Privacy Act (FIPPA), for application of services delivered by the Ministry of Health on your behalf (or for a “Health Care Group” in which you are a registered member), including:
• Application for an OHIP Billing Number
• Changes to Health Care Group Registration Information
To be used for all applications for Home Oxygen Therapy funding.
Consent to collect and disclose personal information about the Canadian university, college, and/or facility the applicant has graduated from and the facility they will be completing their return-of-service at.
The Application Form collects information from applicants regarding their contact information, medical practice and education history.
Transfer of ownership of Integrated Community Health Services Centre (ICHSC) licence.
Form 1 - Physician/Nurse Practitioner Report Pursuant to the Mandatory Blood Testing Act, 2006 and O. Reg. 449/07
To support implementation of the Mandatory Blood Testing Act, 2006
The Seniors Co-Payment Program Application is available on the Ontario Drug Benefit Program Online Applications and Forms website:
https://forms.ontariodrugbenefit.ca/.
If you are not able to complete the form online, please contact the SCP at 416-503-4586 (Toronto area) or 1-888-405-0405 (outside Toronto) for a paper version of this form.
Licensees of Integrated Community Health Services Centres (ICHSCs) must submit an application and obtain written approval from the Director of Integrated Community Health Services Centres prior to a centre’s relocation. For the purposes of this application, a “Fixed Site” centre is a licensed ICHSC where the Limitations and Conditions of the licence specify a single geographic location or address where specified services may be provided.
The Trillium Drug Program Application is available on the Ontario Drug Benefit Program Online Applications and Forms website:
https://forms.ontariodrugbenefit.ca/.
If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.
User Agreement for Pharmacies Requesting Publicly Funded Influenza Vaccine in accordance with the UIIP Prequalification form for health care agencies and workplaces that are required to prequalify in order to receive influenza vaccine.
Application to the Board for a review of a finding of incapacity to manage property under subsection 20.2(1) of the Substitute Decisions Act
This form is to be completed by a Specialty-Service Provider who provides an OHIP-insured service to a patient who is eligible for a Northern Health Travel Grant (NHTG).
IMPORTANT: This form is to be used only for the purpose of patients looking to submit NHTG applications via the NHTG Online Form. This form must be included as an attachment and submitted via the NHTG Online Form, which you can access at the following location:
https://forms.mgcs.gov.on.ca/dataset/on00817
If you wish to submit by mail, please complete the NHTG Application available on the ministry website:
https://forms.mgcs.gov.on.ca/dataset/0327-88
Laboratory Requisition Pursuant to the Mandatory Blood Testing Act, 2006 and O. Reg. 449/07
To support implementation of the Mandatory Blood Testing Act, 2006
PPLBP forms gather necessary information to help determine the applicant eligibility for the program.
The eForm is currently unavailable at this time. We would like to have the option to re-activate the eForm at a later date.
This form is meant to be submitted by a practicing Ontario physician on behalf of their patients to request consideration of funding for out-of-country health services. Along with the completed application form, submissions must also include relevant medical documentation.
The ICHSC Program must be notified of a change in quality assurance advisor through the submission of the Quality Assurance Advisor form which must be signed by both the centre’s quality assurance advisor and the licensee.
