Forms - Central Forms Repository (CFR)

014-4769-85
Appointment & Acknowledgement of Quality Assurance Advisor

The ICHSC Program must be notified of a change in quality assurance advisor through the submission of the Quality Assurance Advisor form which must be signed by both the centre’s quality assurance advisor and the licensee.

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014-3891-22
Clinician Aid C - (Secondary) "Medical Practitioner" or "Nurse Practitioner" Medical Assistance in Dying Aid

Complete 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.

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014-3890-22
Clinician Aid B - (Primary) “Medical Practitioner” or “Nurse Practitioner” Medical Assistance in Dying Aid

The 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.

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014-4931-87
Annual Deductible Re-Assessment Request

This form is available on the Ontario Drug Benefit Program Online Applications and Forms website : https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.

014-5095-87
Consent to the Ministry of Health Collection and/or Disclosure of Personal Health Information for Ontario Drug Benefit Program Recipients

This form is available on the Ontario Drug Benefit Program Online Applications and Forms website: https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.

014-4928-87
Updating Private Insurance for Trillium Drug Program

This form is available on the Ontario Drug Benefit Program Online Applications and Forms website: https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.

014-4930-87
Request to Remove a Household Member(s) from the Trillium Drug Program

This form is available on the Ontario Drug Benefit Program Online Applications and Forms website : https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.

014-4929-87
Trillium Drug Program Application Signature Request

This form is available on the Ontario Drug Benefit Program Online Applications and Forms website: https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.

014-4423-87
Notification for Change of Information for Trillium Drug Program

This form is available on the Ontario Drug Benefit Program Online Applications and Forms website: https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.