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
Application to the Board to Amend the Conditions of, or Terminate the Appointment of a Representative under Subsection 305(8) or (9) of the Child, Youth and Family Services Act.
The purpose of this form is for a patient to provide their consent to disclose Personal Health Information to a an NHTG program-approved Third-Party Agency and agree to direct the ministry to pay the entirety of the eligible Northern Health Travel Grant amount to the approved Third-Party Agency listed in the form.
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.
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.
Consent Form for the Inherited Metabolic Diseases (IMD) Program
The Application form collects information from employers to determine their eligibility for funding through the PA Career Start Program.
