MOHLTC - OHIP Forms and Applications for Health Care Professionals

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OHIP Forms and Applications for Health Care Professionals

Forms are in Portable Document Format (PDF). To view and print the forms, you need to have Adobe Acrobat® Reader installed on your computer. You can download this free software from the Adobe Web site.

Click on the form title to open the form. You can fill-in the form on your screen and print it, or use the disk icon on the Reader toolbar to save a blank copy of the form to your computer. Filled-in forms cannot be saved.

Link to Public OHIP Forms and Applications

4520-84	Prior Approval Application for Full Payment of Insured Out-of-Country (OOC) Health Services
4521-84	Prior Approval Application OOC - Request for Diagnostic Laboratory Testing
4524-84	Prior Approval Application OOC - Emergency/911/CritiCall Transfers
4422-84	Laboratory Requisition
4421-84	Reciprocal Claim
4420-84	Health Claim
4419-84	Request for Laboratory Requisitions / Claim Cards
4347-84	Request for Major Eye Examination
7743-84	Application for Claims Submission and Remittance Advice in Machine-Readable Form
7698-84	Application for Direct Bank Payment
3274-84	Application for GONet Electronic Data Transfer (EDT) Service
3134-84	Application for IVR Participation
3256-82	Application for Reimbursement under the Medical Liability Protection (MLP) Program
0864-84	Authorization for Payment
2404-84	Claims Flagged for Manual Review
3759-83	Community Treatment Order (CTO) Report Log
7178-84	Declaration of Hospital Insurance Coverage
3279-84	Electronic Data Transfer (EDT) Undertaking and Acknowledgement
3343-84	Electronic Data Transfer (EDT) Undertaking and Acknowledgement - Signature Page
1265-84	Health Number Release
7158-84	In-Patient Standard Ward Costs
3889-84	Medical Liability Protection (MLP) Reimbursement Program Authorization
3277-84	Notification of Change for GONet Electronic Data Transfer (EDT) Service
0000-80	Out of Province Claim for Physician Services
7521-84	Out of Province Out-patient Services
3384-83	Registration for Regulated Health Professions
0918-84	Remittance Advice Inquiry
3292-84	Request for Access to the Test Environment for Electronic Data Transfer (EDT) Service
2743-84	Request for Approval of Payment for Proposed Dental Procedures
0691-84	Request for Approval of Payment for Proposed Surgery
7179-84	Summary of Inpatient Expenses



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