-
014-2196-67
Application for Funding Mobility DevicesApplication for Funding Mobility Devices014-1945-67
Application for Funding Ostomy GrantThe information on this form is used to determine eligibility for grant assistance under the Assistive Devices Program.014-4906-87
Fabry Disease Enzyme Replacement Therapy (Agalsidase) AssessmentApplication form for drug therapy for Fabry disease014-4421-84
Reciprocal ClaimClaim card used by physicians to receive reimbursement for reciprocal claims4976-47
Healthcare Provider Notification of MedsCheck ServicesUsing the standardized fax template, pharmacists must share the completed MedsCheck Personal Medication Record with the patient's primary prescriber. A record of the successfully transmitted fax must be kept on file at the pharmacy.014-4860-84
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.014-3766-41
Form 50 - Confirmation of Rights Advice014-4858-87
Request for Ilaris® (canakinumab)Application for drug funding014-0691-84
Request for Approval of Payment for Proposed SurgeryForm to request approval for patient to receive surgery out of Ontario014-4744-84
IHP Application for Direct Bank PaymentForm used by IHPs to set up direct bank deposit014-5063-67
Addendum for Ventilator Equipment and Supplies Application FormAddendum for Ventilator Equipment and Supplies Application014-4807-69
Application for Reduction in Long-Term Care Home Basic Accommodation - Schedule C: Continuation of Previous Dependant DeductionTo be used by residents of LTC homes who would like to apply for a reduction in the amount of their basic accommodation fees. This schedule should be used with one of the four main forms. An applicant should use this schedule if their LTC home has notified them that they are eligible for a “Continuation of Previous Dependant Deduction”.014-4940-87
Exceptional Access Program (EAP) Request OxyNEO (Oxycodone Hydrochloride Controlled Release) TabletsThe 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.
