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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.014-4818-69
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.014-4367-84
Primary Health Care New Patient Declarationform used so that new patient to primary health group can join that group due to reasons on form014-4752-84
Undertaking by Interdisciplinary Health Providers (IHP) for Participation in Machine Readable Input (MRI)Form that Interdisciplinary Health Providers will complete and sign agreeing to conform to ministry's technical specifications for claims submission in MRI014-4721-84
IHP Electronic Data Transfer (EDT) Undertaking and Acknowledgement for Nurse Practitioners (NP)Form used as part of EDT registration package for IHPs014-4750-84
Application for IHP GONet Electronic Data Transfer (EDT) ServiceIHPs apply to submit claim information via EDT014-4521-84
Application for Prior Approval for Full Payment of Insured Out-of-Country (OOC) & Out-of-Province (OOP) Laboratory & Genetics TestingThe OOC/OOP PA Program eForm is designed to be completed and submitted electronically for application for prior approval for full payment of insured Out-of-Country (OOC) & Out-of-Province (OOP) laboratory and genetics testing services. English and French versions can be completed online or downloaded and saved for future use.014-4817-69
Long-Term Care Home Support Document List - Submitting NOA that included benefit(s) that a resident is no longer receiving because they have transitioned to new benefit(s)To 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 have a Notice of Assessment from the year when they were 64 years of age.014-3889-22
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.014-4311-82
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 card014-4340-84
Primary Care - Time and Location of After Hours ServicesForm used to record hours of physicians in after hours clinics
