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014-0225-47
Funding Enrollment for E.S.R.D. PatientsTo register ESRD patients for Special Drug Program for provision of Eythropoietins.014-4652-87
Request for Myozyme®014-3975-87
Visudyne Therapy Registration/Funding EnrollmentApplication for reimbursement of cost due to use of Visudyne014-4846-87
Request for Aldurazyme®To facilitate prescribers making reimbursement claims for treatment of Hurler-Scheie and Hurler disease014-4777-87
Request for Zavesca® - Niemann Pick Type C (NPC)To facilitate prescribers making reimbursement claims for treatment of Niemann Pick Type C (NIPC).014-4717-87
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.014-4723-87
Submission of Patient Evidence Patient Advocacy Groups - Registration FormTo allow patient advocacy groups to register into the database so that they provide written submissions to the ministry on a drug; the form is to make sure all the appropriate information is provided.014-4406-87
Request for an Unlisted Drug Product - Exceptional Access Program (EAP)For faster decisions, prescribers can use the SADIE online portal to submit requests to the Exceptional Access Program (EAP). Sign in through GO Secure (https://www.ebse.health.gov.on.ca) and select SADIE from the services drop-down menu. Visit the SADIE website for more information: http://www.ontario.ca/sadie. Alternatively, this form can be used for submitting requests to the EAP by fax.014-4591-87
Request for Elaprase®To facilitate physician's in making an EAP request for funding/reimbursement of Elaprase for Hunter's Syndrome.014-3057-87
Nutrition ProductsUsed for obtaining authorization for nutrition products as an ODB benefit under certai circumstances014-3889-22
Clinician Aid A - Patient Request for Medical Assistance in DyingThe use of this aid is voluntary. It is being provided to assist you in making a written request for medical assistance in dying that complies with the legal requirements. Once you complete this request, you should provide it to your doctor or nurse practitioner. The completed aid may be included in your medical records and may be used by your doctor or nurse practitioner to provide health care to you.014-4818-69
Long-Term Care Home Support Document List - Resident Receiving ODSPTo be used by residents of LTC homes who would like to apply for a reduction in the amount of their basic accommodation fees. This document guides applicants in determining which supporting documents will be required as part of their application. This document is to be used by applicants who are receiving benefits from the Ontario Disability Support Program.014-4311-82
Health Card Re-RegistrationForm is generated by client communication system to have people replace red&white card with photo health card014-1948-95
Application for Direct Bank Payment - ADPUsed by clients/vendors to receive remuneration by direct deposit versus cheque.014-0280-82
Change of InformationForm used to change status of OHIP coverage - i.e., change of address, name, citizenship status, etc. or to cancel OHIP coverage or replacement of lost, stolen and damaged card014-3384-83
Application for OHIP Billing Number for Health ProfessionalsPhysicians complete form to apply for OHIP billing number and/or specialty billing number.014-4431-84
Primary Health Care Unattached Patient Declarationform used, in urgent cases (i.e. patient was in hospital, newborn in NICU) where patient has no family physician so can join primary group.014-0265-82
Registration for Ontario Health CoverageForm is used to register new or returning Ontario residents or renew photo Health Card and contains instructions/information.014-4297-82
Health Card RenewalForm is generated by client communication system to have people come in to renew photo health card
