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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.014-4818-69
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 supplies014-4919-57
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.014-0005-54
Certificate of DeathCertificate of Death – Form 1 to be completed by an attending physician or registered nurse in the extended class pursuant to s. 17(2)(a) of Reg. 965 – Hospital Management made under the Public Hospitals Act.014-3653-41
Dental Claim014-4580-64
Notice of Adverse Test Results and Issue ResolutionThe Notice of Adverse Test Results and Issue Resolution form is to be used by licensed laboratories and owners/operators of small drinking water systems to support required written notifications pertaining to small drinking water system adverse water quality incidents (AWQI).014-4471-44
Restricting Access to Patient Records In theOntario Laboratories Information SystemComplete this form if you wish to have the Ministry of Health and Long-Term Care restrict access to your laboratory test information in the Ontario Laboratories Information System (OLIS) after your lab test has been completed.014-4578-64
Laboratory Services Notification (LSN)The Laboratory Services Notification (LSN) form is to be used by small drinking water system owners/operators to notify the local public health unit in writing as to which licensed laboratories will test drinking water samples for their small drinking water systems.014-4897-64
Statement of Conscience or Religious Belief – Immunization of School Pupils ActA parent must complete a Statement of Conscience or Religious Belief and have it witnessed by a commissioner for taking affidavits if they wish to obtain a non-medical exemption for their child from vaccine requirements under the Immunization of School Pupils Act.014-4941-87
Exceptional Access Program (EAP) Request Fragmin (Dalteparin Sodium) TherapyThe purpose of the e-Form is to assist physicians in the EAP drug request process by integrating all the rules/criteria into an interactive e-Form that will ensure all the necessary information is captured.014-4895-64
Statement of Medical Exemption – Immunization of School Pupils ActA physician or nurse practitioner must complete a Statement of Medical Exemption for children who require a medical exemption from vaccine requirements under the Immunization of School Pupils Act.014-5052-45
AEMCA Examination Withdrawal and Refund ApplicationThe withdrawal form is to be completed by individuals who have applied and paid to write the Ministry of Health (MOH) Advanced Emergency Medical Care Assistant (AEMCA) exam and now wish to withdraw from the exam.
