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014-4896-64
Notice of Transfer from a School - Immunization of School Pupils ActNotice of Transfer from a School - Immunization of School Pupils Act014-06-5040
Long-Term Care Home Inspection Report RequestAll Long-Term Care Home (LTCH) Inspection reports are posted on the Long-Term Care Homes public website (http://publicreporting.ltchomes.net/en-ca/default.aspx), in English. To request an accessible version or a French version of an Inspection report for a specific LTCH, please complete this form and submit it to the Health Data Branch (HDB), Ministry of Health and Long-Term Care.014-4431-84
Primary Health Care Unattached Patient Declarationform used, in urgent cases (i.e. patient was in hospital, newborn in NICU) where patient has no family physician so can join primary group.014-4853-44
Reinstating Access to Information in the Ontario Laboratories Information System (OLIS)Complete this form if you wish to have the Ministry of Health and Long-Term Care reinstate your laboratory test information in the Ontario Laboratories Information System (OLIS) after your lab test has been completed.014-0005-54
Certificate of DeathCertificate of Death – Form 1 to be completed by an attending physician or registered nurse in the extended class pursuant to s. 17(2)(a) of Reg. 965 – Hospital Management made under the Public Hospitals Act.014-2404-84
Claims Flagged for Manual Reviewform submitted with claims to provide additional information regarding particular claim014-3057-87
Nutrition ProductsUsed for obtaining authorization for nutrition products as an ODB benefit under certai circumstances014-4575-64
Vaccine Cold Chain Incident Exposure/Wastage ReportUsed by public health units to report vaccine cold chain incidents and wasted or exposed vaccine.014-4311-82
Health Card Re-RegistrationForm is generated by client communication system to have people replace red&white card with photo health card014-4406-87
Request for an Unlisted Drug Product - Exceptional Access Program (EAP)For faster decisions, prescribers can use the SADIE online portal to submit requests to the Exceptional Access Program (EAP). Sign in through GO Secure (https://www.ebse.health.gov.on.ca) and select SADIE from the services drop-down menu. Visit the SADIE website for more information: http://www.ontario.ca/sadie. Alternatively, this form can be used for submitting requests to the EAP by fax.014-0280-82
Change of InformationForm used to change status of OHIP coverage - i.e., change of address, name, citizenship status, etc. or to cancel OHIP coverage or replacement of lost, stolen and damaged card014-9998-82
Ontario Health Insurance Plan (OHIP) Document ListThis is accompaniment to Registration for OHIP & Change of Information forms. Lists acceptable ID documents when applying for Ontario health coverage.014-4258-82
Health Card Renewal - ChildForm is generated by client communication system.014-0000-80
Out of Province Claim for Physician ServicesUnder Interprovincial agreement, for travel within Canada, patients/physicians submit form to get reimbursed by applicable health plan.014-4316-84
Patient Enrolment Batch Headerform placed on top of bundles of primary care forms, to submit to ministry for processing.014-0225-47
Funding Enrollment for E.S.R.D. PatientsTo register ESRD patients for Special Drug Program for provision of Eythropoietins.014-4971-67
Vendor AgreementThe 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 establishes contracts with vendors in order to ensure that ADP funding for clients are in accordance with Program policies.014-3523-87
Ontario Drug Programs Enrollment Form
