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014-1819-67
Application for Equipment Listing Wheelchairs, Positioning and Ambulation AidsThis form is used by manufacturers/distributors of mobility equipment (wheelchairs and wheeled walkers) for the purpose of making application to the Assistive Devices Program requesting approval to list their respective products on the list of approved devices.014-3437-67
Application for Funding of Changes/Modifications/New Options to ADP Approved DevicesThis form is used by manufacturers/distributors of mobility equipment (wheelchairs and wheeled walkers) for the purpose of making application to the Assistive Devices Program requesting approval to list their respective products on the list of approved devices.014-5119-84
Consent Authorization Form: Disclosure of Personal Claims History (PCH) Information to Third PartyReceive information required to prove consent provided by individuals or individual's decision makers in order to process Personal Claims History information requests from Third Parties.014-2983-88
Confirmation of Payment Instruction014-3884-41
Review Findings014-3883-41
Program Funding Request014-2002-41
Approval to Purchase Clothing014-4971-67
Vendor AgreementThe Ministry of Health and Long-Term Care's Assistive Devices Program provides customer centered support and funding to Ontario residents who have long-term physical disabilities to provide access to personalized assistive devices appropriate for the individual's basic needs. To accomplish this goal the ADP establishes contracts with vendors in order to ensure that ADP funding for clients are in accordance with Program policies.014-4918-57
Request for Rights Advice Mental Health InpatientUsed by Mental Health Inpatient Unit staff to request Rights Advice. Form is completed when a physician issues a Mental Health Act form that requires the provision of Rights Advice. Fax form to the PPAO and Rights Adviser will be assigned014-4442-97
Return Authorization for Resalable Drugs and Medical SuppliesUse this form if you ordered drugs and/or medical supplies from OGPMSS and wish to return resalable drugs and/or medical supplies to OGPMSS. OGPMSS will only accept returns and provide credit for resalable drugs or supplies that meet the criteria listed on the form. OGPMSS will provide you with a Return Authorization Number within 2 business days upon receipt of a completed form.014-5048-45
AEMCA Examination ApplicationThe application form is for candidates who have either successfully completed the Paramedic training program provided by an approved College or Training Institution or have been considered equivalent through the MOH Standard Paramedic Equivalency Process and wish to write to write the Ministry of Health (MOH) Advanced Emergency Medical Care Assistant (AEMCA) examination.014-06-5040
Long-Term Care Home Inspection Report RequestAll Long-Term Care Home (LTCH) Inspection reports are posted on the Long-Term Care Homes public website (http://publicreporting.ltchomes.net/en-ca/default.aspx), in English. To request an accessible version or a French version of an Inspection report for a specific LTCH, please complete this form and submit it to the Health Data Branch (HDB), Ministry of Health and Long-Term Care.014-4853-44
Reinstating Access to Information in the Ontario Laboratories Information System (OLIS)Complete this form if you wish to have the Ministry of Health and Long-Term Care reinstate your laboratory test information in the Ontario Laboratories Information System (OLIS) after your lab test has been completed.014-0406-67
Authorizer Agreement with the Assistive Devices ProgramThe Ministry of Health and Long-Term Care's Assistive Devices Program provides customer centered support and funding to Ontario residents who have long-term physical disabilities to provide access to personalized assistive devices appropriate for the individual's basic needs. To accomplish this goal the ADP must establish relationships with health professionals in order to ensure that ADP clients are assessed for cost-effective devices that best suit their needs.014-5125-20
Ontario Seniors Dental Care Program ApplicationYou may use this application form to apply for the Ontario Seniors Dental Care Program if you and your spouse (if applicable) have filed your Personal Tax Return(s) with Canada Revenue Agency (CRA) for the most recent tax year and have a valid Social Insurance Number (SIN). If you have a spouse (married or common law partner) who would also like to apply for the Program, they must complete their own application form.014-5126-20
Ontario Seniors Dental Care Program Application Through GuarantorYou may use this application form to apply for the Ontario Seniors Dental Care Program if you do not have a valid Social Insurance Number (SIN) and/or if you have not filed your Personal Tax Return(s) with Canada Revenue Agency (CRA) for the most recent tax year. If you have a spouse (married or common law partner) who would also like to apply for the Program, they must complete their own application form.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.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.
