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014-7158-84
In-Patient Standard Ward Costsform used for inpatients to Ontario hospitals who are here visiting from other provinces014-2404-84
Claims Flagged for Manual Reviewform submitted with claims to provide additional information regarding particular claim014-4316-84
Patient Enrolment Batch Headerform placed on top of bundles of primary care forms, to submit to ministry for processing.014-3164-84
Health Card Medical Exemption RequestForm completed to request exemption, i.e., no photo to appear on photo health card014-0691-84
Request for Approval of Payment for Proposed SurgeryForm to request approval for patient to receive surgery In-Province.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 MOHLTC014-3134-84
Application For IVR ParticipationProvider/hospital applies for Interactive Voice Response to verify Health Card numbers via telephone014-4747-84
Application for IHP Claims Submission and Remittance Advice in Machine Readable Input (MRI)IHPs requesting approval to submit their claims in MRI format014-4594-84
Fact Sheet - Gift of Life Consent Form - Organ and Tissue Donor Registrationaccompanied with form completed by clients to record their wishes for organ/tissue donation014-1265-84
Health Number ReleaseHospitals submit form to ministry to obtain Health Number of patient when number is not available014-4431-84
Primary Health Care Unattached Patient Declarationform used, in urgent cases (i.e. patient was in hospital, newborn in NICU) where patient has no family physician so can join primary group.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.014-4652-87
Request for Myozyme®014-6430-41
Form 4 - Certificate of Renewal014-4323-04
Notice of Withdrawal014-3653-41
Dental Claim014-2983-88
Confirmation of Payment Instruction014-3887-41
Home Staff Change Notification014-3884-41
Review Findings014-3883-41
Program Funding Request
