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014-3233-87
Seniors Co-Payment Program ApplicationThe Seniors Co-Payment Program Application is available on the Ontario Drug Benefit Program Online Applications and Forms website: https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the SCP at 416-503-4586 (Toronto area) or 1-888-405-0405 (outside Toronto) for a paper version of this form.014-4825-67
Application for Funding Communication AidsUsed to apply for Funding for Communication Aids014-4824-67
Application for Funding Visual AidsUsed to apply for Funding for Visual Aids014-4823-67
Application for Funding Pressure Modification DevicesUsed to apply for Funding for Pressure Modification Devices014-4821-67
Application for Funding Maxillofacial Extraoral ProsthesesFor Specialist physician & ADP registered authorizers to request funding for extraoral (facial) prostheses.014-4820-67
Application for Funding Maxillofacial Intraoral ProsthesesFor Specialist physician & ADP registered authorizer to request funding for intraoral (mouth) prostheses.014-4819-67
Application for Funding Orthotic DevicesUsed by Canadian board -certified orthotists registered with ADP to request funding for custom -made orthoses014-4658-67
Application for Funding Ocular ProsthesesUsed to apply for Funding for Ocular Prostheses014-4537-67
Application for Funding Insulin Pumps and Supplies for AdultsApplication used to determine elegibility for funding by ADP for insulin pumps and supplies014-3183-67
Application for Funding Limb ProsthesesUsed by Amputee Team, registered with ADP to request funding for conventional upper/lower limb prosthees.014-4446-67
Application for Funding Insulin Pumps and Supplies for ChildrenUsed by clients to request funding assistance for Insulin Pumps and Supplies for Children014-4564-85
Licence Transfer ApplicationTransfer of ownership of Integrated Community Health Services Centre (ICHSC) licence.on00520
Relocation Application (Fixed Site)Licensees of Integrated Community Health Services Centres (ICHSCs) must submit an application and obtain written approval from the Director of Integrated Community Health Services Centres prior to a centre’s relocation. For the purposes of this application, a “Fixed Site” centre is a licensed ICHSC where the Limitations and Conditions of the licence specify a single geographic location or address where specified services may be provided.014-4900-85
Physician Affiliation Authorization and Declaration of Professional Standing for ICHSCsThe form is used to confirm a physician's qualifications to provide the requested services prior to processing a request to affiliate to a particular ICHSC. The licensee must ensure that the physician has been affiliated to the centre before they begin to provide licensed services.014-4769-85
Appointment & Acknowledgement of Quality Assurance AdvisorThe ICHSC Program must be notified of a change in quality assurance advisor through the submission of the Quality Assurance Advisor form which must be signed by both the centre’s quality assurance advisor and the licensee.014-4645-87
Respiratory Syncytial Virus (RSV) Prophylaxis for High Risk Infants Program EnrolmentTo provide healthcare practitioners a standard form to enroll their patients in this program based on listed clinical criteria.014-5034-64
Healthy Smiles Ontario Parent Notification Form (PNF) Emergency and Essential Services Stream (EESS)This form is to be used by Public Health Units after dental screening to notify parents/guardians that their child has an emergency and/or essential dental condition(s). Parents/Guardian will complete the form and return it to the Public Health Unit to let them know that the child has initiated treatment or to attest to financial hardship and enroll into the Emergency and Essential Services Stream of Healthy Smiles Ontario.014-5035-64
Healthy Smiles Ontario Parent Notification Preventive Services Only Stream (HSO-PSO)This form is to be used by Public Health Units after dental screening to notify parents/guardians that their child would benefit from preventive dental services. If the parent/guardian can complete the form and return it to the Public Health Unit if they wish to enroll their child into the Preventive Services Only Stream of Healthy Smiles Ontario.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 paid