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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 MOHLTC014-4638-67
Authorizer Application - Attachment BAuthorizer Application - Attachment B014-4749-84
IHP Electronic Data Transfer (EDT) Undertaking and AcknowledgementForm related to EDT process for IHPs014-4420-84
Health Claim5127
Ontario Seniors Dental Care Program. Authorizing or Cancelling a RepresentativeYou may use this form to authorize the program administrator of the Ontario Seniors Dental Care Program to deal with another person (such as your spouse or common-law partner, other family member, friend, or accountant) as your representative for program matters. The same form can be used to cancel a previously-made authorization.014-4746-84
Interdisciplinary Health Provider (IHP) Health Number ReleaseForm submitted to ministry to obtain Health Number of patient when not available014-4750-84
Application for IHP GONet Electronic Data Transfer (EDT) ServiceIHPs apply to submit claim information via EDTon00315
Consent Form for the Inherited Metabolic Diseases (IMD) ProgramConsent Form for the Inherited Metabolic Diseases (IMD) Program014-4573-84
Primary Health Care Request to Change Designated Physician - Group EnrolmentUsed by primary care groups who have opted for group enrolment and consent and is only for changing the designated physician of individual patients.014-2045-67
Release of Information About Previous FundingWritten consent to release information enables the Assistive Devices Program to provide a history of previously funded equipment/supplies to a client and/or third party as specified.014-2784-87
Drug Benefit Claim Submission FormUsed by pharmacies for submitting claims014-4652-87
Request for Myozyme®014-5024-41
Form 4A - Certificate of Continuation014-4340-84
Primary Care - Time and Location of After Hours ServicesForm used to record hours of physicians in after hours clinics014-1903-67
Statement of Support for Device Listing Wheelchairs, Positioning and Ambulation AidsThis form is used by manufacturers/distributors of mobility equipment (wheelchairs and wheeled walkers) for the purpose of making application to the Assistive Devices Program requesting approval to list their respective products on the list of approved devices.014-4874-77
Pregnancy and Parental Leave Benefits Program (for Physicians)PPLBP forms gather necessary information to help determine the applicant eligibility for the program.
