Form Othp-003 - Ontario Temporary Health Program Consent Form printable pdf download

Form Othp-003 - Ontario Temporary Health Program Consent Form

ONTARIO TEMPORARY HEALTH PROGRAM

CONSENT FORM

INSTRUCTIONS: To be completed with Claimant on initial claim submission.

CONSENT (ALL FIELDS ARE REQUIRED)

consent to the Ministry of Health and Long-Term

Care (“ministry”), its agent Medavie Blue Cross (“Medavie”) and my health care provider(s) collecting my personal information from

Citizenship and Immigration Canada, and from this form, to use in administering the Ontario Temporary Health Program (“OTHP”).

I also consent to the Ministry, its agent Medavie and my health care provider(s) collecting and using my personal information, and

disclosing it to each other, for the purpose of administering the OTHP.

I understand that this consent will remain in effect until I am no longer eligible for Interim Federal Health Program (IFHP) coverage.

I understand that I am not required to give this consent, and that I may withdraw my consent at any time by providing notice in writing

to Medavie Blue Cross at:

OTHP

Medavie Blue Cross

644 Main St. PO Box 6000

Moncton, NB, E1C 0P9

The individual signing this form must indicate if s/he is consenting for him/herself as the Claimant, or for another individual, as described

below:

I am the claimant consenting for myself

I am a parent consenting for my child who is under 12 years of age

I am an adult, consenting for an incapable adult who is:

q My spouse/partner

q My parent q My brother/sister

q My relative

Signature:

Date:

Witness (print):

Witness Signature:

CLAIMANT INFORMATION (ALL FIELDS ARE REQUIRED)

Certificate Number

Language Preference

q English

q French q Other (specify)

Last Name

First Name

Initial

Birth Date (dd/mm/yy)

Sex

Telephone Number (with area code)

q Male

q Female

Address Street & No.

City or Town

Province

Postal Code

PROVIDER INFORMATION (ALL FIELDS ARE REQUIRED)

Provider Name

Provider Number

Telephone Number

Form Othp-003 - Ontario Temporary Health Program Consent Form

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