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014-4551-87
Application and Consent for the Inherited Metabolic Diseases (IMD) ProgramFor physicians and patients to apply for the Inherited Metabolic Disorders (IMD) Program.014-3266-54
Application for Reduction of Assessed Co-payment FeesThis 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.7219-41
Form 17 - Notice to the Board of the Need to Schedule a Mandatory Review of a Patient's Involuntary Status under Subsection 39(4) of the ActNotice to the Board of the Need to Schedule a Mandatory Review of a Patient's Involuntary Status under Subsection 39(4) of the Act014-7521-84
Out of Province Out-patient Servicesform used for out-patient services incurred by visitors from another province014-4367-84
Primary Health Care New Patient Declarationform used so that new patient to primary health group can join that group due to reasons on form014-4901-97
Requisition for NaloxoneRequisition for Naloxone014-4721-84
IHP Electronic Data Transfer (EDT) Undertaking and Acknowledgement for Nurse Practitioners (NP)Form used as part of EDT registration package for IHPs014-3437-67
Application for Funding of Changes/Modifications/New Options to ADP Approved DevicesThis 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.014-4818-69
Long-Term Care Home Support Document List - Resident Receiving ODSPTo be used by residents of LTC homes who would like to apply for a reduction in the amount of their basic accommodation fees. This document guides applicants in determining which supporting documents will be required as part of their application. This document is to be used by applicants who are receiving benefits from the Ontario Disability Support Program.014-1668-69
Application for a Licence to Establish or Maintain and Operate a Nursing HomeApplication for a Licence to Establish or Maintain and Operate a Nursing Home014-4342-84
Primary Care-List of Locations Where Group Serv. are Regularly ProvidedForm to show all group locations where physician services provided014-4751-84
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 EDT
