Part of Nursing Home Inspection Kit

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 form is to be used by applicants who do not have a Notice of Assessment.

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 form is to be used by applicants who have a Notice of Assessment.

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 schedule should be used with one of the four main forms. An applicant should use this schedule if they would like to request a deduction to support an eligible child living in the community.

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 form is to be used by applicants who are receiving benefits from the Ontario Disability Support Program.

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 schedule should be used with one of the four main forms. An applicant should use this schedule if they would like to request a deduction to support an eligible spouse living in the community.

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 form is to be used by applicants who have a Notice of Assessment from the year when they were 64 years of age.

PLEASE NOTE: The Health Assessment Form has been updated as of July 7th, 2025. Practitioners are asked to begin using the new form immediately. However, assessments completed using the old form will be accepted by Ontario Health atHome until December 31st, 2025. This form is to be used for completion of the assessment required under the Fixing Long-Term Care Act, 2021 when a person applies for a determination of eligibility for long-term care home admission. The required assessment is of the applicant’s physical and mental health, and the applicant’s requirements for medical treatment and health care. This assessment must be made by a physician or registered nurse.

Please complete this form if you wish to withdraw your consent to the Ministry of Long-Term Care (MLTC), Ministry of Finance and the Long-Term Care Home Licensee (LTCH Licensee) collecting your income information from the Canada Revenue Agency (CRA) using an Automated Income Verification (AIV) service for the purpose of MLTC assessing and administering your Application for Reduction in Long-Term Care Home Basic Accommodation (Application).

Pursuant to section 187 of the Fixing Long-Term Care Act, 2021, the Director may directly or indirectly collect the information provided in this application to determine the reduced amount payable by the resident for basic accommodation in accordance with section 303 of O. Reg. 246/22 made under the Fixing Long-Term Care Act, 2021. Pursuant to subsection 303(4) of O. Reg. 246/22, the licensee is required to submit this application and retain a copy.

To be filled out by long-term care (LTC) home applicants as part of the process for determination of eligibility for admission to a LTC home. This completed form is for use by Ontario Health atHome, as the designated placement co-ordinators for long-term care homes, as per the Fixing Long-Term Care Act, 2021, s 47(1).