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045-4809-69
Application for Reduction in Long-Term Care Home Basic Accommodation - Resident Without Notice of Assessment (NOA)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.045-4808-69
Application for Reduction in Long-Term Care Home Basic Accommodation - Resident With a Notice of Assessment (NOA)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.014-3891-22
Clinician Aid C - (Secondary) "Medical Practitioner" or "Nurse Practitioner" Medical Assistance in Dying AidComplete this voluntary aid (Clinician Aid C) if you have been asked by a “Medical Practitioner” or “Nurse Practitioner” to provide a written opinion confirming that the Patient meets the eligibility criteria to receive medical assistance in dying. You should also include the completed aid in the patient's medical records.014-4815-69
Rate Reduction Application in Long-Term Care - Document List Required for Assessment of Resident EligibilityTo 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 have a Notice of Assessment.014-4816-69
Rate Reduction Application in Long-Term Care - Document List Required for Assessment of Resident without NOATo 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 do not have a Notice of Assessment.014-4900-85
Physician Affiliation Authorization and Declaration of Professional Standing for ICHSCsThe form is used to confirm a physician's qualifications to provide the requested services prior to processing a request to affiliate to a particular ICHSC. The licensee must ensure that the physician has been affiliated to the centre before they begin to provide licensed services.014-4807-69
Application for Reduction in Long-Term Care Home Basic Accommodation - Schedule C: Continuation of Previous Dependant DeductionTo 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 their LTC home has notified them that they are eligible for a “Continuation of Previous Dependant Deduction”.014-0691-84
Request for Approval of Payment for Proposed SurgeryForm to request approval for patient to receive surgery In-Province.045-2308-69
Profile of Long-Term Care FacilityPart of Nursing Home Inspection Kit4975-47
MedsCheck Patient Acknowledgement of Professional Pharmacy ServiceThe ministry is introducing an annual process for patient acknowledgement of professional pharmacy services. This is facilitated with the use of a mandatory form and when completed by the patient confirms the patient's understanding of MedsCheck.045-4806-69
Application for Reduction in Long-Term Care Home Basic Accommodation - Schedule B: Child DependantTo 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.014-3890-22
Clinician Aid B - (Primary) “Medical Practitioner” or “Nurse Practitioner” Medical Assistance in Dying AidThe use of this aid is voluntary. It is being provided to assist you in maintaining records of requests for medical assistance in dying. Please use this aid if you are a “Medical Practitioner” or “Nurse Practitioner” and a patient is requesting medical assistance in dying and it is your intention to provide medical assistance in dying to the patient. You should also include the completed aid in the patient's medical records.014-4521-84
Application for Prior Approval for Full Payment of Insured Out-of-Country (OOC) & Out-of-Province (OOP) Laboratory & Genetics TestingThe OOC/OOP PA Program eForm is designed to be completed and submitted electronically for application for prior approval for full payment of insured Out-of-Country (OOC) & Out-of-Province (OOP) laboratory and genetics testing services. English and French versions can be completed online or downloaded and saved for future use.045-4805-69
Application for Reduction in Long-Term Care Home Basic Accommodation - Schedule A: Spouse DependantTo 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.045-4804-69
Application for Reduction in Long-Term Care Home Basic Accommodation Resident Receiving ODSP FormTo 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.
