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.
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.
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 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.
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
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
This 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.
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.
Form 3 - Respondent 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 form is used to confirm a physician's qualifications to provide the requested services prior to processing a request to affiliate to a particular ICHSC. The licensee must ensure that the physician has been affiliated to the centre before they begin to provide licensed services.
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.
