MOHLTC - OHIP Forms and Applications for Health Care Professionals

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OHIP Forms and Applications for Health Care Professionals

Forms are listed alphabetically 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.

To print, use the printer icon on the Reader toolbar. For form sizes larger than 8.5 x 11 inches, check the Fit to Page box in the print menu window. See the Forms and Applications main menu page for detailed instructions.

OHIP Forms and Applications for Public

4422-84	Laboratory Requisition	Paper Copy View & Print FILL & PRINT
4421-84	Reciprocal Claim	Paper Copy View & Print FILL & PRINT
4420-84	Health Claim	Paper Copy View & Print FILL & PRINT
4419-84	Request for Laboratory Requisitions / Claim Cards	Paper Copy View & Print FILL & PRINT
4347-84	Request for Major Eye Examination	Paper Copy View & Print FILL & PRINT
7743-84	Application for Claims Submission and Remittance Advice in Machine-Readable Form	PAPER COPY ONLY FILL & PRINT
7698-84	Application for Direct Bank Payment	PAPER COPY ONLY FILL & PRINT
3274-84	Application for GONet Electronic Data Transfer (EDT) Service	FILL & PRINT
3134-84	Application for IVR Participation	FILL & PRINT
3256-82	Application for Reimbursement of Malpractice Fees	FILL & PRINT
3307-74	Application for Registration to the Service Retention Initiative (SRI)	PAPER COPY ONLY FILL & PRINT
3276-84	Approval Notification for GONet Electronic Data Transfer (EDT) Service	FILL & PRINT
0864-84	Authorization for Payment	FILL & PRINT
2404-84	Claims Flagged for Manual Review	FILL & PRINT
3759-83	Community Treatment Order (CTO) Report Log	VIEW & PRINT
7178-84	Declaration of Hospital Insurance Coverage	FILL & PRINT
3279-84	Electronic Data Transfer (EDT) Undertaking and Acknowledgement	FILL & PRINT
3343-84	Electronic Data Transfer (EDT) Undertaking and Acknowledgement - Signature Page	VIEW & PRINT
1265-84	Health Number Release	FILL & PRINT
7158-84	In-Patient Standard Ward Costs	FILL & PRINT
3889-84	Malpractice Reimbursement Participation	PAPER COPY ONLY FILL & PRINT
3277-84	Notification of Change for GONet Electronic Data Transfer (EDT) Service	FILL & PRINT
0000-80	Out of Province Claim for Physician Services	FILL & PRINT
7521-84	Out of Province Out-patient Services	PAPER COPY ONLY VIEW & PRINT
1442-84	Prior Approval Application for Full Payment of Insured Out-of-Country Health Services	FILL & PRINT
3384-83	Registration for Regulated Health Professions	FILL & PRINT
0918-84	Remittance Advice Inquiry	PAPER COPY ONLY FILL & PRINT
3292-84	Request for Access to the Test Environment for Electronic Data Transfer (EDT) Service	FILL & PRINT
2743-84	Request for Approval of Payment for Proposed Dental Procedures	VIEW & PRINT
0691-84	Request for Approval of Payment for Proposed Surgery	FILL & PRINT
7179-84	Summary of Inpatient Expenses	FILL & PRINT



Call the ministry INFOline at 1-800-268-1154 (Toll-free in Ontario only) In Toronto, call 416-314-5518 TTY 1-800-387-5559 Hours of operation : 8:30am - 5:00pm