This form is to be completed by a Specialty-Service Provider who provides an OHIP-insured service to a patient who is eligible for a Northern Health Travel Grant (NHTG).
IMPORTANT: This form is to be used only for the purpose of patients looking to submit NHTG applications via the NHTG Online Form. This form must be included as an attachment and submitted via the NHTG Online Form, which you can access at the following location:
https://forms.mgcs.gov.on.ca/dataset/on00817
If you wish to submit by mail, please complete the NHTG Application available on the ministry website:
https://forms.mgcs.gov.on.ca/dataset/0327-88
Used by clients to request funding assistance for Insulin Pumps and Supplies for Children
The information on this form is used to determine eligibility for grant assistance under the Assistive Devices Program.
To facilitate prescribers making reimbursement claims for treatment of Hurler-Scheie and Hurler disease
This 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.
Form 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 card
Application for Rehabilitation Assessor/Fitter/Dispenser Status
Form used by IHPs to set up direct bank deposit
Used to determine whether a person who is eligible for homemaking and nurses services is required to pay the fees prescribed for the services.
Form used as part of EDT registration package for IHPs
Used by primary care groups who have opted for group enrolment and consent and is only for changing the designated physician of individual patients.
