-
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.014-0225-47
Funding Enrollment for E.S.R.D. PatientsTo register ESRD patients for Special Drug Program for provision of Eythropoietins.014-3759-83
Community Treatment Order (CTO) Report Logform used to provide patient with a comprehensive plan of community-based treatment or care and supervision.014-3164-84
Health Card Medical Exemption RequestForm completed to request exemption, i.e., no photo to appear on photo health card014-4723-87
Submission of Patient Evidence Patient Advocacy Groups - Registration FormTo allow patient advocacy groups to register into the database so that they provide written submissions to the ministry on a drug; the form is to make sure all the appropriate information is provided.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 telephone014-3384-83
Application for OHIP Billing Number for Health ProfessionalsPhysicians complete form to apply for OHIP billing number and/or specialty billing number.014-4747-84
Application for IHP Claims Submission and Remittance Advice in Machine Readable Input (MRI)IHPs requesting approval to submit their claims in MRI format014-0000-80
Out of Province Claim for Physician ServicesUnder Interprovincial agreement, for travel within Canada, patients/physicians submit form to get reimbursed by applicable health plan.014-4311-82
Health Card Re-RegistrationForm is generated by client communication system to have people replace red&white card with photo health card014-4406-87
Request for an Unlisted Drug Product - Exceptional Access Program (EAP)For faster decisions, prescribers can use the SADIE online portal to submit requests to the Exceptional Access Program (EAP). Sign in through GO Secure (https://www.ebse.health.gov.on.ca) and select SADIE from the services drop-down menu. Visit the SADIE website for more information: http://www.ontario.ca/sadie. Alternatively, this form can be used for submitting requests to the EAP by fax.014-4594-84
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 available014-3889-22
Clinician Aid A - Patient Request for Medical Assistance in DyingThe use of this aid is voluntary. It is being provided to assist you in making a written request for medical assistance in dying that complies with the legal requirements. Once you complete this request, you should provide it to your doctor or nurse practitioner. The completed aid may be included in your medical records and may be used by your doctor or nurse practitioner to provide health care to you.
