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006-fro-014
Third Party Authorization FormThe Third Party Authorization form authorizes a person other than the payor or recipient to act on the payor's or recipient's behalf. A Family Responsibility Office (FRO) support payor or support recipient may designate this person to request and receive information from the FRO regarding their case.014-1057-82
(Change of Address form) What's Your Address?Form used to update/change address information of OHIP cardholders014-3975-87
Visudyne Therapy Registration/Funding EnrollmentApplication for reimbursement of cost due to use of Visudyne014-1948-95
Application for Direct Bank Payment - ADPUsed by clients/vendors to receive remuneration by direct deposit versus cheque.014-4846-87
Request for Aldurazyme®To facilitate prescribers making reimbursement claims for treatment of Hurler-Scheie and Hurler disease014-3266-54
Application for Reduction of Assessed Co-payment FeesThis form is to be used for a patient who is seeking a reduction to the co-payment or for whom a reduction is sought further to the factors set out in section 10 of Reg. 552 under the Health Insurance Act.014-0280-82
Change of InformationForm used to change status of OHIP coverage - i.e., change of address, name, citizenship status, etc. or to cancel OHIP coverage or replacement of lost, stolen and damaged card014-4637-67
Application for Rehabilitation Assessor/Fitter/Dispenser StatusApplication for Rehabilitation Assessor/Fitter/Dispenser Status014-4744-84
IHP Application for Direct Bank PaymentForm used by IHPs to set up direct bank deposit014-2861-69
Consent to Inspect Assets Form 2Used to determine whether a person who is eligible for homemaking and nurses services is required to pay the fees prescribed for the services.014-4721-84
IHP Electronic Data Transfer (EDT) Undertaking and Acknowledgement for Nurse Practitioners (NP)Form used as part of EDT registration package for IHPs014-4573-84
Primary Health Care Request to Change Designated Physician - Group EnrolmentUsed by primary care groups who have opted for group enrolment and consent and is only for changing the designated physician of individual patients.014-4777-87
Request for Zavesca® - Niemann Pick Type C (NPC)To facilitate prescribers making reimbursement claims for treatment of Niemann Pick Type C (NIPC).014-4717-87
Submission of Patient EvidenceTo provide patient advocacy groups with a template for written submissions to the ministry on a drug; the form is to make sure all the appropriate information is provided.014-4342-84
Primary Care-List of Locations Where Group Serv. are Regularly ProvidedForm to show all group locations where physician services provided014-0265-82
Registration for Ontario Health CoverageForm is used to register new or returning Ontario residents or renew photo Health Card and contains instructions/information.014-2743-84
Request for Approval of Payment for Proposed Dental Proceduresform completed to obtain approval for dental procedures to be carried out in hospital and covered by OHIP014-4340-84
Primary Care - Time and Location of After Hours ServicesForm used to record hours of physicians in after hours clinics014-4752-84
Undertaking by Interdisciplinary Health Providers (IHP) for Participation in Machine Readable Input (MRI)Form that Interdisciplinary Health Providers will complete and sign agreeing to conform to ministry's technical specifications for claims submission in MRI
