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on00421
Real-time Continuous Glucose Monitor RenewalUsed to renew funding for rtCGMon00313
Request to End Household Enrolment in the Trillium Drug ProgramThis form is available on the Ontario Drug Benefit Program Online Applications and Forms website: https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.014-5095-87
Consent to the Ministry of Health Collection and/or Disclosure of Personal Health Information for Ontario Drug Benefit Program RecipientsThis form is available on the Ontario Drug Benefit Program Online Applications and Forms website: https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.014-4928-87
Updating Private Insurance for Trillium Drug ProgramThis form is available on the Ontario Drug Benefit Program Online Applications and Forms website: https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.014-4930-87
Request to Remove a Household Member(s) from the Trillium Drug ProgramThis form is available on the Ontario Drug Benefit Program Online Applications and Forms website : https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.014-4929-87
Trillium Drug Program Application Signature RequestThis form is available on the Ontario Drug Benefit Program Online Applications and Forms website: https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.014-4423-87
Notification for Change of Information for Trillium Drug ProgramThis form is available on the Ontario Drug Benefit Program Online Applications and Forms website: https://forms.ontariodrugbenefit.ca/. If you are not able to complete the form online, please contact the TDP at 416-642-3038 (Toronto area) or 1-800-575-5386 (outside Toronto) for a paper version of this form.014-4564-85
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.014-5035-64
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.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.014-5037-67
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.014-4297-82
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.014-3889-84
Medical Liability Protection (MLP) Reimbursement Program Authorization/ Direct Deposit RequestPhysicians complete form to indicate their preference on how malpractice reimbursement will be sent to them.
