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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.014-4420-84
Health Claimon00314
Request for Prior Approval for Full Payment of Insured Out-of-Country (OOC) Health ServicesThis 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.014-4421-84
Reciprocal ClaimClaim card used by physicians to receive reimbursement for reciprocal claims014-4478-84
Adjustmentonline form to be available to providers and to Regional Operations staff on a permanent basis on the internet014-1948-95
Application for Direct Bank Payment - ADPUsed by clients/vendors to receive remuneration by direct deposit versus cheque.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.014-7179-84
Summary of Inpatient Expensesform sent to other provinces for reimbursement of inpatient claims paid (reciprocal)on00700
Laboratory Licensing and X-Ray Inspection Services Fees PaymentTo facilitate secure and real-time electronic payments for clinical laboratory licences and x-ray facility application fees using debit and credit cards.014-7158-84
In-Patient Standard Ward Costsform used for inpatients to Ontario hospitals who are here visiting from other provinces014-2404-84
Claims Flagged for Manual Reviewform submitted with claims to provide additional information regarding particular claim014-4316-84
Patient Enrolment Batch Headerform placed on top of bundles of primary care forms, to submit to ministry for processing.014-4347-84
Request for Major Eye Examinationform to be completed by those eligible for eye exams to be covered under OHIP014-3384-83
Application for OHIP Billing Number for Health ProfessionalsPhysicians complete form to apply for OHIP billing number and/or specialty billing number.014-0691-84
Request for Approval of Payment for Proposed SurgeryForm to request approval for patient to receive surgery In-Province.014-7521-84
Out of Province Out-patient Servicesform used for out-patient services incurred by visitors from another province014-4406-87
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.014-3889-22
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.014-0000-80
Out of Province Claim for Physician ServicesUnder Interprovincial agreement, for travel within Canada, patients/physicians submit form to get reimbursed by applicable health plan.
