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014-4537-67
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 paid014-4344-64
Influenza Vaccine Order Form for the Universal Influenza Immunization ProgramEligibility Criteria for Trivalent Inactivated Influenza Vaccine.014-4891-84
Request for Disclosure of Personal Claims History Information to a Third PartyForm authorizes the ministry to disclose an individual's personal claims history information directly to a third party.on00502
Laboratory RequisitionLaboratory Requisition Pursuant to the Mandatory Blood Testing Act, 2006 and O. Reg. 449/07 To support implementation of the Mandatory Blood Testing Act, 2006014-5037-67
Renewal of Funding Home Oxygen TherapyUsed to renew funding for home oxygen therapy.014-0406-67
Authorizer Agreement with the Assistive Devices ProgramThe Ministry of Health and Long-Term Care's Assistive Devices Program provides customer centered support and funding to Ontario residents who have long-term physical disabilities to provide access to personalized assistive devices appropriate for the individual's basic needs. To accomplish this goal the ADP must establish relationships with health professionals in order to ensure that ADP clients are assessed for cost-effective devices that best suit their needs.014-4574-64
Vaccine Cold Chain Maintenance Inspection ReportUsed by public health units when conducting cold chain maintenance inspections in premises that store publicly funded vaccines.014-5033-64
Healthy Smiles Ontario Emergency and Essential Services Stream (HSO-EESS) Application FormThis form is to be used by fee-for-service dental providers to enroll clients into the Emergency and Essential Services Stream of Healthy Smiles Ontario.014-4297-82
Health Card RenewalForm is generated by client communication system to have people come in to renew photo health card014-4890-84
Request for Access to Personal Claims History (PCH) Information by Individual or Individual's Substitute Decision MakerReceive information required to process Personal Claims History information requests from individuals or individual's substitute decision makers.