Document Category: Forms

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Medical Referral Paediatric for patients under 18 years of age.
Patients may have care in a nursing clinic and be taught their treatments based on nurses discretion.

For Adults 18 years +
First dose requests may take longer to process and the decision to administer the first dose parenteral medication is made by the Service Provider.

North Simcoe Muskoka Medical Referral Form Adult

Nursing services are primarily provided in clinics, with in-home care only by exception. Prescribers must ensure therapy is appropriate and safe; first dose requests may take longer and are at the nursing provider’s discretion. Patients receive self-management teaching and follow-up, and services are not duplicated. Ineligible medications include blood products, naturopathic, and experimental treatments.

Nursing services are primarily provided in clinics, with in-home care only by exception. Prescribers must ensure therapy is appropriate and safe; first dose requests may take longer and are at the nursing provider’s discretion. Patients receive self-management teaching and follow-up, and services are not duplicated. Ineligible medications include blood products, naturopathic, and experimental treatments.

Nursing services are primarily provided in clinics, with in-home care only by exception. Prescribers must ensure therapy is appropriate and safe; first dose requests may take longer and are at the nursing provider’s discretion. Patients receive self-management teaching and follow-up, and services are not duplicated. Ineligible medications include blood products, naturopathic, and experimental treatments.

For Adults 18 years +
First dose requests may take longer to process and the decision to administer the first dose parenteral medication is made by the Service Provider.

Nursing services are primarily provided in clinics, with in-home care only by exception. Prescribers must ensure therapy is appropriate and safe; first dose requests may take longer and are at the nursing provider’s discretion. Patients receive self-management teaching and follow-up, and services are not duplicated. Ineligible medications include blood products, naturopathic, and experimental treatments.

Nursing services are primarily provided in clinics, with in-home care only by exception. Prescribers must ensure therapy is appropriate and safe; first dose requests may take longer and are at the nursing provider’s discretion. Patients receive self-management teaching and follow-up, and services are not duplicated. Ineligible medications include blood products, naturopathic, and experimental treatments.

For Adults 18 years +
First dose requests may take longer to process and the decision to administer the first dose parenteral medication is made by the Service Provider.

For Adults 18 years +
First dose requests may take longer to process and the decision to administer the first dose parenteral medication is made by the Service Provider.

For Adults 18 years +
First dose requests may take longer to process and the decision to administer the first dose parenteral medication is made by the Service Provider.

For Adults 18 years +
First dose requests may take longer to process and the decision to administer the first dose parenteral medication is made by the Service Provider.

For Adults 18 years +
First dose requests may take longer to process and the decision to administer the first dose parenteral medication is made by the Service Provider.

For Adults 18 years +
First dose requests may take longer to process and the decision to administer the first dose parenteral medication is made by the Service Provider.

For Adults 18 years +
First dose requests may take longer to process and the decision to administer the first dose parenteral medication is made by the Service Provider.

For Adults 18 years +
First dose requests may take longer to process and the decision to administer the first dose parenteral medication is made by the Service Provider.

For Adults 18 years +
First dose requests may take longer to process and the decision to administer the first dose parenteral medication is made by the Service Provider.

For Adults 18 years +
First dose requests may take longer to process and the decision to administer the first dose parenteral medication is made by the Service Provider.

For Adults 18 years +
First dose requests may take longer to process and the decision to administer the first dose parenteral medication is made by the Service Provider.

Nursing services are primarily provided in clinics, with in-home care only by exception. Prescribers must ensure therapy is appropriate and safe; first dose requests may take longer and are at the nursing provider’s discretion. Patients receive self-management teaching and follow-up, and services are not duplicated. Ineligible medications include blood products, naturopathic, and experimental treatments.

Nursing services are primarily provided in clinics, with in-home care only by exception. Prescribers must ensure therapy is appropriate and safe; first dose requests may take longer and are at the nursing provider’s discretion. Patients receive self-management teaching and follow-up, and services are not duplicated. Ineligible medications include blood products, naturopathic, and experimental treatments.

Nursing services are primarily provided in clinics, with in-home care only by exception. Prescribers must ensure therapy is appropriate and safe; first dose requests may take longer and are at the nursing provider’s discretion. Patients receive self-management teaching and follow-up, and services are not duplicated. Ineligible medications include blood products, naturopathic, and experimental treatments.

Nursing services are primarily provided in clinics, with in-home care only by exception. Prescribers must ensure therapy is appropriate and safe; first dose requests may take longer and are at the nursing provider’s discretion. Patients receive self-management teaching and follow-up, and services are not duplicated. Ineligible medications include blood products, naturopathic, and experimental treatments.

Nursing services are primarily provided in clinics, with in-home care only by exception. Prescribers must ensure therapy is appropriate and safe; first dose requests may take longer and are at the nursing provider’s discretion. Patients receive self-management teaching and follow-up, and services are not duplicated. Ineligible medications include blood products, naturopathic, and experimental treatments.

Nursing services are primarily provided in clinics, with in-home care only by exception. Prescribers must ensure therapy is appropriate and safe; first dose requests may take longer and are at the nursing provider’s discretion. Patients receive self-management teaching and follow-up, and services are not duplicated. Ineligible medications include blood products, naturopathic, and experimental treatments.

Nursing services are primarily provided in clinics, with in-home care only by exception. Prescribers must ensure therapy is appropriate and safe; first dose requests may take longer and are at the nursing provider’s discretion. Patients receive self-management teaching and follow-up, and services are not duplicated. Ineligible medications include blood products, naturopathic, and experimental treatments.

Nursing services are primarily provided in clinics, with in-home care only by exception. Prescribers must ensure therapy is appropriate and safe; first dose requests may take longer and are at the nursing provider’s discretion. Patients receive self-management teaching and follow-up, and services are not duplicated. Ineligible medications include blood products, naturopathic, and experimental treatments.

Nursing services are primarily provided in clinics, with in-home care only by exception. Prescribers must ensure therapy is appropriate and safe; first dose requests may take longer and are at the nursing provider’s discretion. Patients receive self-management teaching and follow-up, and services are not duplicated. Ineligible medications include blood products, naturopathic, and experimental treatments.

Chatham Branch: Tel: 519 351-5677
Fax: 519-351-5842

Sarnia Branch: Tel: 519-337-1000
Fax: 519-337-4331

Windsor Branch: Tel: 519-258-8211
Fax: 519-258-6288

Fax form to CBA team at 519-742-0635

Highland Retirement Home
20 Fieldgate St, Kitchener, ON

Stone Lodge Retirement Residence
165 Cole Rd, Guelph, ON

FAX COMPLETED FORM TO Ontario Health atHome: 519-742-0635
How is Crisis defined?
A patient is considered to be “In Crisis” if:
1. Patient and/or caregiver safety is at risk and/or there is a risk that a significant health event and/or challenging end-of-life symptoms cannot be managed in their current setting
2. Patient at risk of requiring ED or acute care admission
3. Community resources have been exhausted and family/ caregivers are unable to cope with the patient’s care needs
4. There is a risk that the services required to meet the patient’s end-of-life care plan goals may not be available in their current setting
5. Patient at risk of not accessing their preferred place of death (considering recent trajectory of the PPS score).

Pediatric Patients at McMaster Children’s Hospital (MCH) Hamilton
Toll Free Phone Number: 1-800-810-0000

To order care relating to the Protocol for Home Parenteral Nutrition (PPN or TPN) for pediatric patients at McMaster Children’s Hospital. Contact HNHB at 1-800-810-0000

Fax completed form to 1-866-655-6402
Note –If patient is receiving treatment through Ontario Health atHome the medication will be provided to the patient through Calea. Do not have patient pick the medication up from their own pharmacy.

Form ONC 537 E MR22 for Service Providers
Nursing Agency to fax the completed and/or reviewed HPP to the appropriate Primary Health Care Provider(s) and Funeral Director (if consent obtained).
Nursing Agency to send completed and/or revised HPP to Ontario Health atHome via Health Partner Gateway (HPG).
When HPG is unavailable, fax to:
Chatham: 519-351-5842
Windsor: 519-258-6288
Sarnia: 519-337-4331

Effective September 30, 2025
Fax: 1-855-697-7358

*Hospital: Use hospital Ontario Health atHome fax number

Effective September, 2025
Fax: 1-855-697-7358

*Hospital: Use hospital Ontario Health atHome fax number

Effective September 30, 2025
Fax: 1-855-697-7358
*Hospital: Use hospital Ontario Health atHome fax number

Please Fax Hospice applications and eShift PCCRs as these are considered Urgent.

Phone: 800-263-3877
Fax: 855-352-2555

This form is to be used for completion of the assessment required under the Fixing Long-Term Care Act, 2021 when a person applies for a determination of eligibility for long-term care home admission. The required assessment is of the applicant’s physical and mental health, and the applicant’s requirements for medical treatment and health care. This assessment must be made by a physician or registered nurse.

You may choose up to five (5) long-term care homes (LTCH). Please list LTCHs in order of preference. You must be prepared to accept whichever one becomes available first, however, you can then wait in that LTCH for your first choice to become available.

Coordinated Bed Access referrals are coordinated by Ontario Health atHome WW. The Hospital will be sharing your medical and personal information with Ontario Health atHome WW. Ontario Health atHome WW will add your name to the waiting list. Your initials and gender will be accessible to Ontario Health atHome WW’s other hospital partners. The hospital and Ontario Health atHome WW will share your medical and personal information with the Rehabilitation program.

Office Location: 180 Riverview Dr, Chatham
Fax: 1-519-258-6288

Completed by a Coordinated Bed Access Coordinator (Ontario Health atHome staff) for transfers in the rehab bed program.
Please fax completed form and updated letter of understanding to Ontario Health atHome (519) 742-0635
For Neurobehavioural and Geriatric Assessment Units fax to (519) 749-4326

Fax: 1-855-697-7358

*Hospital: Use hospital Ontario Health atHome fax number

Last Update: June 2025
Fax: 1-855-697-7358

*Hospital: Use hospital Ontario Health atHome fax number

Fax: 1-855-697-7358

*Hospital: Use hospital Ontario Health atHome fax number

Medical Equipment and Supply Fax Number: 1-855-697-7358

*Hospital: Use hospital Ontario Health atHome fax number

Palliative Symptom Relief Kit (SRK) – Temiskaming District – Kirkland Lake Area Prescriber Order Form
NOTE: This form must be faxed to Ontario Health atHome at 705-567-9407

Palliative Symptom Relief Kit (SRK) – Sudbury Prescriber Order Form
Please fax to Ontario Health atHome Care Coordinator @ 705-522-3855
The Ontario Health atHome Care Coordinator will send a copy of the form to:
• Robinson’s Pharmacy Sudbury
• Community Nursing Provider

Palliative Symptom Relief Kit (SRK) – Sault Ste. Marie Prescriber Order Form
FAX to: Ontario Health at Home 705-949-1663

Palliative Symptom Relief Kit (SRK) – Parry Sound Prescriber Order Form
ONLY a Ontario Health atHome Healthcare Provider may access kit for first dose. To be dispensed with Supply kit (SIV 0220).
Please fax to 1-855-773-4056.The Care Coordinator will send a copy of the form to: Pharmasave Lane Family Pharmacy & Community Nursing Provider

Palliative Symptom Relief Kit (SRK) – North Bay Prescriber Order Form
Please fax completed form to Robinson’s Pharmasave
• North Bay Location (705) 495-4059 (Nipissing Region/Sturgeon Falls/Burk’s Falls/New Liskeard)
• Sudbury Location (705) 560-6751 (Sudbury/Parry Sound/Port Loring)

Palliative Symptom Relief Kit (SRK) – Manitoulin Island Prescriber Order Form
1. Prescribers: Fax to patients pharmacy of choice:
I. Guardian Pharmacy – Gore Bay (705-282-0792), Little Current (705-368-2077),
Manitowaning (705-859-2280), or Mindemoya (705-377-5310)
II. Edgewater Pharmacy – Little Current (705-368-3131)
AND
2. Pharmacists: Fax to Ontario Health atHome (705-522-3855) to ensure CC can order supplies to
patients pharmacy of choice

Palliative Symptom Relief Kit (SRK) – Cochrane District – Kapuskasing Prescriber Order Form
Procedure:
1. Place your initials and ✪dosing in the column of the table for any medications to be included in the SRK.
2. Fax to Ontario Health atHome at (705-267-7795)
3. Fax to patient’s participating pharmacy of choice:
i. Wal-Mart (855-983-1050)
ii. Shopper’s Drug Mart (705-337-1661)
iii. Rexall (705-337-1877)
4. Family to pick-up SRK & Supplies at dispensing pharmacy.
5. SRK is for short term use only. Prescriptions must be sent for ongoing use for specific medications needed.

Timing and placement of the Symptom Response Kit (SRK) requires careful consideration (i.e. prognosis is less than six months; patient expected to deteriorate quickly) with goal of avoiding emergency room visit or hospital admission.
Medications in the SRK will expire; therefore, will need to be reviewed and reordered by the physician/Nurse Practitioner (NP) if it remains appropriate. Consider reviewing goals of care and expected home death protocols

Long-Term Care Home Crisis Choice List | Choix des foyers de soins de longue durée en cas de Crise

Please select up to five long-term care homes for short stay respite, including any out-of-Champlain choices, and rank them in order of your preference. The applicant’s name will be added to the wait lists for the chosen homes if eligible, and if the chosen long-term care homes can provide the required care. Ontario Health atHome will confirm with you the availability of the requested dates.

Please select up to five long-term care homes for short stay interim and rank them in order of your preference.
The applicant’s name will be added to the wait listsfor the chosen homesif eligible, and if the chosen long-term care homes can provide the required care.
Ontario Health atHome will notify you about the eligibility. Short Stay Interim beds are available to all hospital Alternative Levels of Care to long-term care patient.

Champlain, Liste de choix de foyers de soins de longue durée

The following checklist is a reference tool for Ontario Health atHome care coordinators, individuals applying to long-term care and their substitute decision maker(s).
Key items related to the application process are listed below and are to be checked off after the information is provided by the care coordinator to the applicant and/or their substitute decision maker.

Please select up to five long-term care homes from the list below, including those you may be interested in that are located outside of the Champlain region.

Completed by a Primary Care Physician or Registered Dietician

Acute Care to Rehab & Complex Continuing Care (CCC) Referral
Referrals are coordinated by Ontario Health atHome Waterloo Wellington. Your health care team will be sharing your
medical and personal information with Ontario Health atHome WW and the rehabilitative care program. Ontario Health
atHome WW will add your name to the waiting list. Your initials and gender will be accessible to Ontario Health atHome
WW’s other hospital partners
Fax Completed Form to 519-742-0635

356 Oxford Street West London, ON N6H 1T3
Telephone: 1-877-900-5667 Fax: 519-657-4578

Please fax to: 807.767.6968 or 1.855.272.6025
If required, Telehomecare staff will fax the referral form to the Primary Care Provider to verify and/or add any relevant information.

Please fax referral forms to: 705-670-3805
If required, Telehomecare staff will fax the referral form to the Primary Care Provider to verify and/or provide any relevant information.
Updated: June 28, 2024

GENERAL INFORMATION & QUESTIONNAIRE. Updated June 28, 2024

NOTE: A current medication list is recommended with each referral. You may use this form or provide a current medication list using your. own agency-specific/primary care provider’s form if it contains the following information. For additional notes fill out this form. Updated June 28, 2024

This form is additional Notes relating to the Referral for Services form. Updated: June 28, 2024

Referral for Central Venous Access Device (CVAD) Through Regional Cancer Program form. Updated June 2024

*Not a pathway or wound type – use guidelines when NPWT is initiated in conjunction with pathway that is appropriate for wound type.

Note: NPWT will continue to be assessed in the community, and settings may be reviewed based on exudate and patient tolerance. Continuation of NPWT is dependent on wound healing goals being met. Maximum treatment time for NPWT is 8 weeks.
Fax: 613-745-6984/1-855-450-8569
*Hospital: Use hospital Ontario Health atHome fax number

Note: NPWT will continue to be assessed in the community, and settings may be reviewed based on exudate and patient tolerance. Continuation of NPWT is dependent on wound healing goals being met. Maximum treatment time for NPWT is 8 weeks.

Note: NPWT will continue to be assessed in the community, and settings may be reviewed based on exudate and patient tolerance. Continuation of NPWT is dependent on wound healing goals being met. Maximum treatment time for NPWT is 8 weeks.

Note: NPWT will continue to be assessed in the community, and settings may be reviewed based on exudate and patient tolerance. Continuation of NPWT is dependent on wound healing goals being met. Maximum treatment time for NPWT is 8 weeks.

Note: NPWT will continue to be assessed in the community, and settings may be reviewed based on exudate and patient tolerance. Continuation of NPWT is dependent on wound healing goals being met. Maximum treatment time for NPWT is 8 weeks.

Note: NPWT will continue to be assessed in the community, and settings may be reviewed based on exudate and patient tolerance. Continuation of NPWT is dependent on wound healing goals being met. Maximum treatment time for NPWT is 8 weeks.

Fax: 905-855-8989 / 1-877-298-8989
*Hospital: Use hospital Ontario Health atHome fax number

Note: NPWT will continue to be assessed in the community, and settings may be reviewed based on exudate and patient tolerance. Continuation of NPWT is dependent on wound healing goals being met. Maximum treatment time for NPWT is 8 weeks.

Note: This form will be effective on July 23, 2024.

NPWT will continue to be assessed in the community, and settings may be reviewed based on exudate and patient tolerance. Continuation of NPWT is dependent on wound healing goals being met. Maximum treatment time for NPWT is 8 weeks.

Note: NPWT will continue to be assessed in the community, and settings may be reviewed based on exudate and patient tolerance. Continuation of NPWT is dependent on wound healing goals being met. Maximum treatment time for NPWT is 8 weeks. Form CS 570 OC 24

Note: NPWT will continue to be assessed in the community, and settings may be reviewed based on exudate and patient tolerance. Continuation of NPWT is dependent on wound healing goals being met. Maximum treatment time for NPWT is 8 weeks.

Note: NPWT will continue to be assessed in the community, and settings may be reviewed based on exudate and patient tolerance. Continuation of NPWT is dependent on wound healing goals being met. Maximum treatment time for NPWT is 8 weeks.

Note: NPWT will continue to be assessed in the community, and settings may be reviewed based on exudate and patient tolerance. Continuation of NPWT is dependent on wound healing goals being met. Maximum treatment time for NPWT is 8 weeks.

Note: NPWT will continue to be assessed in the community, and settings may be reviewed based on exudate and patient tolerance. Continuation of NPWT is dependent on wound healing goals being met. Maximum treatment time for NPWT is 8 weeks.

Note: NPWT will continue to be assessed in the community, and settings may be reviewed based on exudate and patient tolerance. Continuation of NPWT is dependent on wound healing goals being met. Maximum treatment time for NPWT is 8 weeks.

Fax: 613-650-2996
*Hospital: Use hospital Ontario Health atHome fax number

Order form for supplies and equipment needed for Negative Pressure Wound Therapy in the Central West area

Complete the Burlington IPCOT referral form and fax supporting documents to: 905-574-6335
– Medical summary/ health history
– Pertinent diagnostic tests
– Current medication lists
– Pharmacy information
– Consult/ progress notes
– Other notes

Veuillez suivre ces instructions (S’ouvre dans un nouvel onglet)
pour accéder au formulaire.

Formulaire fourni par le ministère des Soins de longue durée en vertu de la Loi de 2021 sur le redressement des soins de longue durée.

Si vous souhaitez être admis dans un foyer de soins de longue durée (SLD), vous devez remplir ce formulaire. Ces renseignements sont requis par Santé à domicile Ontario, le coordonnateur du placement désigné pour les foyers de SLD, afin de déterminer si vous êtes admissible à l’admission. Santé à domicile Ontario peut recueillir d’autres renseignements personnels sur la santé auprès de vos fournisseurs de soins de santé afin de déterminer votre admissibilité. Santé à domicile Ontario peut également utiliser et divulguer les renseignements aux mêmes fins.
Renseignements sur le demandeur

Important Note: Please follow these instructions (opens in a new tab) to access the form.

Form provided by the Ministry of Long-Term Care under the Fixing Long-Term Care Act, 2021.

If you wish to be admitted to a long-term care (LTC) home, you must fill out this form. This information is required by Ontario Health atHome, the designated placement co-ordinator for LTC homes, to determine if you are eligible for admission. Ontario Health atHome may collect additional personal health information from your health care providers
for the purpose of determining your eligibility. Ontario Health atHome may also use and disclose the information for the same purpose.

The Expected Death in the Home (EDITH) protocol supports end-of-life care based on an individual’s expressed wish to die at home and not to be resuscitated when they stop breathing or their heart stops. An expected death refers to when, in the opinion of a health care team, the patient is irreversibly and irreparably terminally ill; that is, there is no available treatment to restore health, or the patient refuses the available treatment.

The submission of this completed form for nursing and supplies facilitates the delivery of the MAiD kit (i.e., supplies only and no medications) to the location you identify below, where the MAID procedure will take place.

Referral/Request for Assessment in South West area. This is a PDF Interactive form. You have the option to complete all or parts, electronically. When completed, please print ad return this form to Ontario Health atHome via fax.
London: 519-472-4045 (patients living in London/Middlesex and Elgin)
Stratford: 519-273-2847 or toll free: 1-855-223-2847 (patients living in Grey/Bruce, Huron, Oxford, Perth)

356 Oxford Street West London, ON N6H 1T3
Telephone: 1-855-474-5754 Fax: 519-472-3257
** Orders with less than 48 hours notice require a call to 519-474-5754 to confirm**
For support, or to ensure receipt of a new order sent between 2:00 pm Friday and 8:00 am Monday (and holidays), please call 519-474-5754

Completed by Primary care Physician to request Home Care services. Patient/Families may also print this referral form to bring to an appointment for completion.
If initiating referral for HPC services, please use Form 031B, “Request for Hospice Palliative Care Services”

Fax: 905-855-8989 / 1-877-298-8989

*Hospital: Use hospital Ontario Health atHome fax number

Toronto Fax: (416) 222-6517
Newmarket Fax: (905) 952-2404

Please complete and fax order form to Ontario Health atHome: 519-472-4045 or 1-855-539-6970
For any additional inquiries please call Ontario Health atHome at 1-855-474-5754

Note: A signed prescription for feed including type and rate, as well as a completed Nutrition Products Form
from the physician must be faxed to the pharmacy providing the feed.
Fax: 519-472-4045

Note: A signed prescription for feed including type and rate, as well as a completed Nutrition Products
Form from the physician must be faxed to the pharmacy providing the feed.
Fax: 519-472-4045

SRK is a temporary or short term solution only.

• The SRK are MD/NP orders to be implemented by a nurse (RN, RPN) when symptoms require urgent intervention to manage acute symptoms and facilitate a comfortable death at home.
• The MRP/NP is to be notified as soon as possible regarding changes in condition necessitating the initiation of orders.
• ALL requested medications must be checked off in the form.

Please fax back to ontario health athome 705‐792‐6270

TO ALL PALLIATIVE CARE PROVIDERS
(For the purpose of this form, an individual refers to a patient or client)
Your submission of this form will be taken to explicitly mean that you have gained appropriate permission for release of the information contained to the agencies and services to whom you are submitting this. Please also include your Organization’s Release of Information Form, if applicable.

Ontario Health atHome Child and Youth Mental Health & Addictions Nursing Program
Fax: 1 (519) 571-3957
A mental health nurse will connect with student, parent and/or guardian to confirm consent and finalize eligibility.

Ontario Health atHome Child and Youth Mental Health & Addictions Nursing Program
Fax: 1 (519) 571-3957
A MH nurse will connect with student, parent and/or guardian to confirm consent and finalize eligibility.

POLICY

1. This is a Physician / Nurse Practitioner (NP) order to be implemented by a Registered Nurse (RN) / Registered Practical Nurse (RPN) when
   symptoms require urgent intervention to facilitate a comfortable home death.
2. The attending Physician/NP is to be notified as soon as possible regarding change in patient’s condition and need for ongoing prescription(s).
3. DNR and plan for expected death should be in place.
4. Completed prescription to be FAXED back to Ontario Health atHome at 416-222-6517 or 905-952-2404

If required, Telehomecare staff will fax the referral form to the Primary Care Provider to verify and/or provide any relevant information.
Chatham Branch: Fax: 519-351-5842
Sarnia Branch: Fax: 519-337-4331
Windsor Branch: Fax: 519-258-6288

This form is to be completed by the School Staff or Hospital Staff referring student. Submit the completed form (page 1) to the
fax number or email address listed on the form
Please Fax Completed Referral To: (905) 952-2407 or Email To: MHAN@ontariohealthathome.ca
Phone: 905-895-1240 or 416-222-2241 or 1-888-470-2222 Ext. 436525

CPS fax: 1-866-675-0885
*Hospital: Use hospital Ontario Health atHome fax number

Wound Care and General Supply Order Form for Central West area

Respiratory Therapy Supply Order Form for Central West area

Ostomy Supply Order Form for Central West area

Fax: 905-855-8989 / 1-877-298-8989

*Hospital: Use hospital Ontario Health atHome fax number

Fax: 905-855-8989 / 1-877-298-8989

*Hospital: Use hospital Ontario Health atHome fax number

Fax: 905-855-8989 / 1-877-298-8989

*Hospital: Use hospital Ontario Health atHome fax number

Windsor Regional Hospital – Ouellette Campus inpatient referral and treatment form

Chatham Site – Fax: 519-351-5842
Sarnia Site – Fax: 519-337-4331
Windsor Site – Fax: 519-258-6288

Medical Supply Reimbursement Form for Eligible Expenses – English – Fillable

Continuous Ambulatory Delivery Device Patient Controlled Analgesia Prescription Order.
Fax completed CADD Prescription/Order forms to Ontario Health atHome at 1-866-839-7299

Formulaire de demande de services

Envoyez par fax au : 613 745-8243 ou 1 855 450-8569

Please fax to: 613.745.8243 or 1.855.450.8569

Through our Available Retirement Care Home Enhanced Supports (ARCHES) to Care Beds Program, we are able to help you move from the hospital to a retirement residence with enhanced supports where you can make important decisions about your future care and living arrangements.

Complete the Request for Ontario Health atHome, Hamilton Niagara Haldimand Brant area, services and fax it to the appropriate location. Refer to page 2 of the form for fax numbers.

Primary Care Partners: in addition to using the form above, you may also connect directly with the Care Coordinator aligned with your office/practice.

For help to complete the form, please call Ontario Health atHome’s central access team at 1-800-869-8828 ext. 4003.

NOTE: Referral processing cannot be initiated unless page 1 of form is complete. Referring physician will be notified re missing & required information as soon as noted, in order to prevent delay in service arrangements.

Fax: 1-844-858-3546/ Toll Free

*Hospital: Use hospital Ontario Health atHome fax number

Fax: 1-844-858-3546/ Toll Free

*Hospital: Use hospital Ontario Health atHome fax number

Fax: 1-844-858-3546/ Toll Free

*Hospital: Use hospital Ontario Health atHome fax number

Fax: 1-844-858-3546/ Toll Free

*Hospital: Use hospital Ontario Health atHome fax number

Fax: 1-844-858-3546/ Toll Free

*Hospital: Use hospital Ontario Health atHome fax number

Urinary Continence Supply Order Form for Central West area

Infusion and Enteral Supplies Order Form for Central West area

By completing this form, the prescriber confirms that all safeguards have been met for the patient to be eligible to receive MAID.
Please ensure form is completed for accuracy. Once completed fax to 1-888-334-6559.

Formulaire de demande pour la divulgation de renseignements personnels. En vertu de la Loi de 2004 sur la protection des renseignements personnels sur la santé Veuillez

The Niagara Palliative Care Outreach Team (PCOT) is a group of specialists, including Nurse Practitioners, Palliative Care Clinician, Navigator and Psychosocial Counsellors.
The services available are:

• Complex pain & symptom management support for end-of-life issues
• Psychosocial-spiritual support, including bereavement follow-up
• Mentorship & coaching

Request for Release of Personal Health Information under the Personal Health Information Protection Act, 2004

Information sheet for patients and families.

For out of region referrals, fax to Ontario Health atHome (OHaH) at:
London Middlesex: 519-472-3257
Elgin: 519-631-6968
Oxford: 519-539-6351
Huron Perth: 519-273-6454
Grey Bruce: 519-881-1425
If admission to Parkwood PCU is urgent, please fax to 519-685-4804 as well as Ontario Health atHome.

To request the services of the Palliative Care Outreach Teams in Haldimand Norfolk

To request the services of the Palliative Care Outreach Team in Hamilton

L’Équipe régionale de consultation en soins palliatifs de Champlain est là pour vous appuyer.

L’Équipe régionale de consultation en soins palliatifs constitue un partenariat entre Soins continus Bruyère et Services de soutien à domicile et en milieu communautaire de Champlain. Nous représentons une équipe interprofessionnelle d’experts en soins palliatifs, y compris des infirmières praticiennes, des infirmières de pratique avancée, des infirmiers spécialisés et des médecins.

The Champlain Regional Palliative Consultation Team (RPCT) is here for you.
The RPCT is a partnership between Bruyère Continuing Care and Ontario Health atHome, Champlain area. We are a team of inter-professional palliative-care experts, including nurse practitioners, advanced practice nurses, nurse specialists and doctors.

To refer a patient to (apply for) hospice and hospice-type services

Referral Form to request the palliative care outreach services in Brant.

Referral for Ontario Health atHome Services in North East

Que sont les soins de convalescence?
Dans le cadre de ce programme de séjour de courte durée, des soins sont fournis jour et nuit dans des foyers de soins de longue durée aux personnes provenant de l’hôpital ou de la communauté qui ont besoin de services médicaux et de services de thérapie particuliers pour retrouver leurs forces, leur endurance et leur mobilité. Le but consiste à permettre aux patients de recouvrer la capacité fonctionnelle nécessaire pendant qu’ils reçoivent des soins de convalescence pour assurer leur sécurité et leur confort dans leur communauté.

Your submission of this form will be taken to explicitly mean that you have gained appropriate permission for release of the information contained to the agencies and services to whom you are submitting this. Please also include your Organization’s Release of Information Form, if applicable.

The Palliative Care Common Referral Form (PC-CRF) has been in use by palliative care organizations across the City of Toronto since 2004. The PC-CRF was originally developed by the Toronto In-Patient Palliative Care subcommittee of the Toronto Palliative Care Network (now known as the Toronto Central Palliative Care Network) in order to standardize the application process to access palliative care services throughout the city.

Please FAX Completed Referral to: Ontario Health atHome School Health Support Services Team VIP Fax Line: Toll Free 1-844-800-4578
Ontario Health atHome School Health Support Services Team VIP Line: Toll Free 1-877-900-5667
An Ontario Health atHome MHAN will contact the student or parent/guardian to determine/confirm consent for appropriate referrals.

For the management of rapid-onset, unanticipated symptoms for patients nearing end–of-life and no longer able to swallow oral medications. The medication on this order form is limited to support short duration of symptom management (48 hours) until further medications are ordered. Note: See Palliative Care Symptom Response Guidelines for more info on how to use the form.

Ontario Health atHome end of life SRK is intended to facilitate timely access to a range of medications to relieve a client’s symptoms in the home on an urgent basis; thereby; potentially avoiding an emergency department and/or acute care admission. Physician orders are indicated below and authorized (signed) by the most responsible
physician (MRP). The nurse can only administer those medications in the kit that have valid signed orders noted on this order form.

Hospital referrers, please contact the Ontario Health atHome hospital care coordinator prior to discharge for an assessment to inform service planning.
Please complete the referral form in its entirety and fax completed form to Ontario Health atHome: 519-472-3257
** The referral will be triaged based on the information provided in this form **

To order general medications, including wound care and maintenance for urinary catheters

Mental Health and Addictions Nursing Program Referral Form for School Board, Community Agencies, etc.

Centralized Diabetes Intake Referral FormFor Access to Diabetes Education Programs and the Centre for Complex Diabetes Care Phone: 1-888-997-9996 Fax: 1-905-444-2544 Toll Free Fax: 1-844-731-2161

Request for Hospice Palliative Care Services – Form 031B, Completed by a Primary Care Physician

Chatham-Kent Health Alliance inpatient referral and treatment form – fillable

Windsor Regional Hospital – Met Campus inpatient referral and treatment form – fillable

Hôtel-Dieu Grace Healthcare inpatient referral and treatment form – fillable

Erie Shores HealthCare inpatient referral and treatment form – fillable

Windsor Regional Hospital – Ouellette Campus emergency referral and treatment form – fillable

Qu’est-ce que le Programme de relève et de réduction de la détresse des soignants?
Votre coordonnateur de soins a déterminé que vous êtes admissible au Programme de relève et de réduction de la détresse des soignants. Le programme prévoit un soutien supplémentaire fourni par les préposés aux services de soutien à la personne (PSSP) pour assurer un répit temporaire aux soignants, réduire le fardeau de ces derniers et/ou éviter l’épuisement professionnel.

Le programme de soins de relève de courte durée offert dans des foyers de soins de longue durée comprend des caractéristiques importantes que les participants ou leur représentant doivent comprendre. Lors de la consultation, le coordonnateur de soins suit la présente liste de vérification afin de s’assurer que le patient capable, le procureur ou le mandataire spécial comprenne bien en quoi consiste le programme.

Paramedic Services will communicate back to Home and Community Care Support Services using the HNHB Community Paramedicine Communication Form.

At Ontario Health atHome, we are committed to leading the advancement of an integrated sustainable health care system that ensures better health, better care and better value. Your feedback is important to us.

Erie Shores HealthCare outpatient referral and treatment form – fillable

Windsor Regional Hospital – Ouellette Campus outpatient referral and treatment form – fillable

Windsor Regional Hospital – Met Campus emergency referral and treatment form – fillable

Windsor Regional Hospital – Met Campus outpatient referral and treatment form – fillable

Up to 24 hours may be required for infusion to be initiated in the home. Incomplete prescriptions may cause delays in processing your order. Please ensure that contact information is provided so that the pharmacy can reach you should they have questions.

Walker assessment eligibility form

Orders are fulfilled per Community Protocols documented on page 2, unless physician requests otherwise. We process only completed referrals
(signed, dated and legible). Confidential when completed. Fax completed form to 613.745.6984 or 1.855.450.8569. If you received this form in error,
please call 1.800.538.0520.

Symptom Response Kit (SRK) Request Order Form Windsor

Referral and treatment plan form – fillable

Providers cupboard usage order form – fillable

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Offloading assessment form – fillable

Medical update request form – wound

Medical update request form

Hôtel-Dieu Grace Healthcare inpatient referral and treatment form – fillable

Integrated Bruyere Outpatient and Community Stroke Rehabilitation Referral Form. Complete and fax to 613-745-8243
If patient requires only a physiatry consult, please use a standard medical consultation form instead

The Short-Stay Respite in Long-Term Care Homes (SSR-LTCH) program includes important features that participants or their designate need to understand. During the required counselling, the Care Coordinator uses this checklist to ensure the capable patient (patient), Power of Attorney (POA), or Substitute Decision Maker (SDM) fully understands the program.

Erie Shores HealthCare emergency referral and treatment form – fillable

Electrical Stimulation (eSTIM) referral assessment form – fillable

Electrical Stimulation (eSTIM) non-formulary order form – fillable

Chatham-Kent Health Alliance outpatient referral and treatment form – fillable

Assessment service plan form – fillable

Bluewater Water Health emergency referral and treatment form – fillable

Bluewater Water Health inpatient referral and treatment form – fillable

Bluewater Water Health outpatient referral and treatment form – fillable

Chatham-Kent Health Alliance emergency referral and treatment form – fillable

La présente liste de vérification a pour but d’assurer que le coordonnateur de soins fournit des conseils au patient, au procureur, ou au mandataire spécial au sujet des plus importants facteurs liés au placement du patient dans un foyer de soins de longue durée. Toutes les déclarations cochées ci-dessous s’appliquent à la situation du patient.

Email offers an easy and convenient way for our patients, their Substitute Decision Makers (SDM) or those appointed with Powers of Attorney (POA) to communicate with their Care Coordinator and Ontario Health atHome.

un moyen facile et pratique pour nos patients, mandataires spéciaux ou fondés de pouvoir de communiquer avec le coordonnateur de soins et le Santé à domicile Ontario.

For patients being discharged home from hospital with a new tracheostomy and laryngectomy care for patients being discharged home from hospital

Mental Health and Addictions Nursing Program Referral Form.

To request the services of the Mental Health & Additions Nurse, the patient must be:

1. A student registered in school and who is no older than 21 years of age (may include home instruction)
2. In need of services or related treatment to an identified and/or suspected mental health and/or addictions issue
3. Aware of and consenting to the referral

Additionally, there must be a clearly defined role for the Mental Health & Addictions Nurse

For hospital partners who use Health Partner Gateway to receive patient referrals.

To clearly communicate a patient’s plan of care relating to the provision of CPR.

To order administration of influenza vaccine

The purpose of this checklist is to ensure the patient – or power of attorney (POA), or substitute decision-maker (SDM) – receives counselling from our Care Coordinator about the most important factors involved in the patient’s placement in a long-term care home (LTCH). Each statement with a check mark beside it, below, applies to the patient’s situation.

To order midline catheter maintenance

To order care relating to vascular access devices in adults (in accordance with the Vascular Access Maintenance Protocol)

To order care relating to the Protocol for Home Parenteral Nutrition (PPN or TPN) for adult patients

To identify who will complete pronouncement and certification of death for an expected death at home

To order first dose IV medications to be administered to patients in the community. First dose requests may take longer to process and are not appropriate for urgent requirements.

To order the administration of ceftriaxone to patients being discharged from the Brantford Community Healthcare System (BCHS)

For Long-Term Care Partners in HNHB. Please complete and fax the Long-Term Care Home Referral for Service form to request one or more of the following services for residents:
• Nursing
• Wound Care
• Speech Language Pathology for Swallowing Assessment

– Patients will receive treatment in our community nursing clinics, unless under exceptional circumstances.
– We process only completed referrals (legible, signed, dated). Fax to 613.745.6984 or 1.855.450.8569.

To order Milrinone Infusion Therapy for adult patients

To be completed and signed by an HCCSS Care Coordinator to refer a patient to Margaret’s Place for Palliative Overnight Respite care

To order Milrinone Infusion Therapy for pediatric patients

Completed by Retirement Home(RH) or HCCSS staff to outline services that a patient is currently receiving or may require if moving to a Retirement Home setting

Completed by Retirement Home staff when requesting a Swallowing Assessment

Patients enrolled in the COVID-19 Remote Monitoring Program use an app on their smartphone to report their symptoms to their nurse.

South West MAID referral form

Request for Type 1 Diabetes Treatment Order

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A referral form to request a virtual wound consult with an NSWOC/WCS/ET or Nurse Practitioner from the South West Regional Wound Care Program.

To be eligible to receive Ontario Health atHome MHAN services the student must be:
– A Registered student (up to age 21) (can include home instruction)
– In need of services or related treatment to an identified and/or suspected mental health and/or addictions issue
– Aware and have consented to the referral

Palliative Care SBAR Communication Tool for Nurses in the South East

Ontario Health atHome – South East referrals from hospital

Home and Community Care Support Services South East Medical Order Form

South East Medical Assistance in Dying Procedural Record

South East Medical Assistance in Dying Assessment Record, Please ensure form is completed and uploaded to patient’s CHRIS file.

Community Medical Referral Form – Central West

Referral for Ontario Health atHome Services in North West

Referral Form for Ontario Health atHome

Champlain Referral Form for Community Referrals

Ontario Health atHome, South East area service request/referral form

Note: To ensure patient safety and care continuity, please complete this Referral Form in full. Palliative referrals are to use the Palliative Care Services Referral Form available at ontariohealthathome.ca

Telehomecare COPD and Heart Failure Referral Form

Formulaire de renvoi pour le programme d’infirmières et d’infirmiers en santé mentale et en toxicomanie – Viamonde

Mental Health and Addictions Nursing Program referral form – Viamonde School Board

Mental Health and Addiction Nursing (MHAN) Program referral form – Toronto District School Board

Mental Health and Addiction Nursing (MHAN) Program referral form – Toronto Catholic District School Board

Formulaire de renvoi pour le programme d’infirmières et d’infirmiers en santé mentale et en toxicomanie pour le conseil scolaire catholique MonAvenir

Mental Health and Addictions Nursing program referrals from hospitals

Referral form for administering COVID-19 antivirals in Toronto Central community nursing clinics.

Centralized Intake and Referral Application to Specialty Hospitals for the Toronto Central area

Behavioural Supports Outreach Programs (BSOT) general referral form for Toronto Central

Adult Speech Language Pathology Referral Form

Telehomecare Referral Form

Palliative Registry Referral Form

Palliative Common Referral Form

Intake and Linking Referral Form

COVID-19 Remote Self-Monitor Referral Form

Clinic Eligibility

Mississauga Halton Symptom Management Kit Prescription/Order Form

Mississauga Halton referral form for palliative services and palliative care nurse practitioner services for adults

Central West – Hospital Medical Referral Form

Mental Health and Addictions Nursing Program Referral Form

Central West Palliative Nurse Practitioner Referral Form

Application for School Health Support Services for the PDSB, DPCDSB, UGDSB, YRDSB, YRCDSB, TDSB, TCDSB, and other school boards

Prescription form for Symptom Management Kit

Telehomecare Referral Form

Formulaire de renvoi à Télésoins à domicile pour les patients atteints d’une maladie pulmonaire obstructive chronique (MPOC) ou d’une insuffisance cardiaque
congestive.

What is Convalescent Care?
This short stay program provides 24-hour care in long-term care homes for people from hospitals or the community who need specific medical and therapy services to regain their strength, endurance and mobility. The goal is for patients to regain significant function during their time in convalescent care to return safely and comfortably to their community.

What is the Caregiver Distress Respite Program?
Your Care Coordinator has determined that you are eligible for this program that offers support to caregivers. To give caregivers temporary respite, the program provides the patient with additional support from personal support workers (PSWs). The aim is to reduce caregiver burden and/or avoid burnout.

Form 552, Notification of Rehabilitative Care, Palliative Care, Transitional Care or Residential Hospice Bed Vacancy

Mental Health & Addiction (MHAN) Nurse Referral. Please fax to: 1-613-650-2992

To order care relating to Home Parenteral Nutrition in the South East. NOTE: Two (2) business days notice required

To ensure that your patient receives I.V. therapy in a timely and efficient manner, be sure to complete ALL areas on this referral form. 24 hour notice may be required depending on availability of the drug, supplies and/or service provider.

Patients enrolled in the COVID-19 Remote Monitoring Program use an app on their smartphone to report their symptoms to their nurse.

Patients enrolled in the COVID-19 Remote Monitoring Program use an app on their smartphone to report their symptoms to their nurse.

Centre-Est, Formulaire de renvoi à Télésoins à domicile pour les patients atteints d’une maladie pulmonaire obstructive chronique (MPOC) ou d’une insuffisance cardiaque congestive.

Central East – COPD and Heart Failure Telehomecare Referral Form

North East – Referral form for administering COVID-19 antivirals in North East community nursing clinics.

Referral form for administering COVID-19 antivirals in North West community.

Windsor Regional Hospital – Met Campus outpatient URO referral and treatment form – fillable

Central East, PrVEKLURY® Remdesivir Infusion Referral Form. Please ensure form is completed for accuracy.

Palliative Symptom Management Kit Order Form, North West

Les patients inscrits au programme de surveillance à distance utilisent une application sur leur téléphone intelligent pour communiquer leurs symptômes à l’infirmière.

Patients enrolled in the COVID-19 Remote Monitoring Program use an app on their smartphone to report their symptoms to their nurse.

Fax cover sheet that can be used to accompany MAID referral document

Completed by a Primary Care Physician

Referral form for administering COVID-19 antivirals in South East community nursing clinics.

Common Palliative Referral Guidelines

Total contact casting treatment and assessment forms – fillable

Central East Medical Assistance in Dying Prescription Order Form

Referral and treatment plan pain medication order form – fillable

Mental Health and Addictions Nursing Program Referral Form

MAID Referral

Hip and Knee Referral Form

Guidelines how to use the Palliative Symptom Response Order Form.

Nursing Care Centre locations throughout HNHB geography.

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Request form under the Freedom of Information and Protection of Privacy Act

To order IV vancomycin and/or aminoglycosides for patients in the community

Authorization for Release of Personal Health Information Form

Patient Appeal Form

Narcotic Infusion Therapy Referral Form

Infusion Therapy Referral Form

Hospital Request for Assessment Form

Hospital Narcotic Infusion Therapy Referral Form

Hospital Infusion Therapy Referral Form

Community Paramedicine Referral Form

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