-
014-4832-84
Primary Health Care Enrolment Material Order FormPhysicians utilise form to order Primary Health Care select forms/materials from vendor.4975-47
MedsCheck Patient Acknowledgement of Professional Pharmacy ServiceThe ministry is introducing an annual process for patient acknowledgement of professional pharmacy services. This is facilitated with the use of a mandatory form and when completed by the patient confirms the patient's understanding of MedsCheck.014-4508-67
Insulin Pump Product EvaluationUsed to evaluate Insulin pumps014-2983-88
Confirmation of Payment Instruction014-4882-83
Oral and Maxillofacial Rehabilitation Program (OMRP) ApplicationForm allows providers to refer patients for assessment for the program and will be used by hospital sites to record patient eligibility.014-4954-64
Public Health Unit Requisition for Specimen Shipping SuppliesPublic Health Unit requisition for specimen shipping supplies for rabies testing014-7179-84
Summary of Inpatient Expensesform sent to other provinces for reimbursement of inpatient claims paid (reciprocal)014-3134-84
Application For IVR ParticipationProvider/hospital applies for Interactive Voice Response to verify Health Card numbers via telephone014-4943-87
Exceptional Access Program (EAP) Request Lovenox (Enoxaparin Sodium) TherapyThe purpose of the e-Form is to assist physicians in the EAP drug request process by integrating all the rules/criteria into an interactive e-Form that will ensure all the necessary information is captured.014-4956-64
Healthy Smiles Ontario – Change of InformationHealthy Smiles Ontario Change of Information form is a paper form submitted by mail as a result of a change during any benefit year. This form is used to add or change information about the applicant, marital status and/or spouse, and children/youth. This form is only required for those who have applied and been enrolled in the core services stream of the program.014-4474e-67
Prior Testing Disclosure - Powered Mobility DevicesThis form is used by Manufacturers to report testing of Powered Mobility Devices014-5055-67
Authorizer Registration Change RequestTo maintain registration of health care professionals, termed authorizers, by the Assistive Devices Program014-4471-44
Restricting Access to Patient Records In theOntario Laboratories Information SystemComplete this form if you wish to have the Ministry of Health and Long-Term Care restrict access to your laboratory test information in the Ontario Laboratories Information System (OLIS) after your lab test has been completed.
