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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 MOHLTC014-0918-84
Remittance Advice InquiryForm used by physicians to make inquiries regarding payment details on Remittance Advice014-0951-84
Out-of-Province/Out-of-Country Claim SubmissionForm used so patient can submit out of country medical receipts014-7698-84
Application for OHIP Direct Bank Payment for Health Care Professionalsform used so physicians can have direct deposit of payment of claims014-3750-84
Organ and Tissue Donor RegistrationForm completed by clients to record their wishes for organ/tissue donation014-4860-84
Vendor Application for Conformance Testing-Acceptable Use PolicyForm outlines the Conformance Testing-Acceptable Use Policy and is part of agreement between ministry and vendor who must successfully pass the conformance testing.014-1265-84
Health Number ReleaseHospitals submit form to ministry to obtain Health Number of patient when number is not available014-4594-84
Fact Sheet - Gift of Life Consent Form - Organ and Tissue Donor Registrationaccompanied with form completed by clients to record their wishes for organ/tissue donation014-4431-84
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.014-4891-84
Request for Disclosure of Personal Claims History Information to a Third PartyForm authorizes the ministry to disclose an individual's personal claims history information directly to a third party.014-4890-84
Request for Access to Personal Claims History (PCH) Information by Individual or Individual's Substitute Decision MakerReceive information required to process Personal Claims History information requests from individuals or individual's substitute decision makers.014-3889-84
Medical Liability Protection (MLP) Reimbursement Program Authorization/ Direct Deposit RequestPhysicians complete form to indicate their preference on how malpractice reimbursement will be sent to them.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.014-4521-84
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.3977-84
Health Care Provider Claim - Diagnostic and Treatment ServicesForm created with public health. Eligible uninsured patients diagnosed/treated for TB, physicians submit form to get paid014-4652-87
Request for Myozyme®014-6430-41
Form 4 - Certificate of Renewal014-4323-04
Notice of Withdrawal014-3887-41
Home Staff Change Notification
