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014-7698-84
Application for OHIP Direct Bank Payment for Health Care Professionalsform used so physicians can have direct deposit of payment of claims014-4589-64
Response to Adverse Drinking Water Quality Incidents - IssueThis form is completed by Public Health Boards when MOH site is down.014-4575-64
Vaccine Cold Chain Incident Exposure/Wastage ReportUsed by public health units to report vaccine cold chain incidents and wasted or exposed vaccine.014-4751-84
Interdisciplinary Health Provider (IHP) Nurse Practitioner (NP) Authorization for Participation in the NP Service Encounter Reporting and Tracking (SERT) InitiativeForm will be used for NPs to become affiliated with an organization and participate in the NP Service Encounter Tracking and Reporting (SERT) Initiative to receive funding from the MOHLTC014-4406-87
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.014-4344-64
Influenza Vaccine Order Form for the Universal Influenza Immunization ProgramEligibility Criteria for Trivalent Inactivated Influenza Vaccine.014-2203-64
Toronto Clients Requisition for Biological Supplies (for use in M postal code areas only)Used by Toronto Clients to order Biological Supplies from Ontario Government Pharmaceutical and Medical Supply Service.014-4574-64
Vaccine Cold Chain Maintenance Inspection ReportUsed by public health units when conducting cold chain maintenance inspections in premises that store publicly funded vaccines.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.014-4537-67
Application for Funding Insulin Pumps and Supplies for AdultsApplication used to determine elegibility for funding by ADP for insulin pumps and supplies014-3750-84
Organ and Tissue Donor RegistrationForm completed by clients to record their wishes for organ/tissue donation014-4860-84
Vendor Application for Conformance Testing-Acceptable Use PolicyForm outlines the Conformance Testing-Acceptable Use Policy and is part of agreement between ministry and vendor who must successfully pass the conformance testing.014-4919-57
Request for Rights Advice Community Treatment Order (CTO)Used by Mental Health Professional to request Rights Advice for both patient and SDM (if indicated). Form completed when Community Treatment Plan (CTP) and Form 49 are issued by physician. Form, CTP and Form 49 faxed to PPAO.014-4372-64
Universal Influenza Immunization Program Reimbursement FormUniversal Influenza Immunization Program Reimbursement Form for influenza immunization clinics that are eligible for reimbursement through the Universal Influenza Immunization Program.014-4455-64
Universal Influenza Immunization Program Pharmacy FormUniversal Influenza Immunization Program Pharmacy Form for influenza immunization clinics that are eligible for reimbursement through the Universal Influenza Immunization Program.014-4917-67
Vendor Registration ApplicationThe Vendor Registration Application form is an interactive form that will be completed by an Ontario retailer or supplier of assistive devices who is requesting registration with the Assistive Devices Program.014-3264-54
Hospital Chronic Care Co-payment FormCalculation of Chronic Care Co-Payments for use by hospital staff, patients, and families.
