Central area

*Requests are only for Hospital to Home (H2H) patients already being supported by H2H program within the community
**Hospital based patients are to be initiated as per hospital Ontario Health atHome processes
Please fax completed form to Ontario Health atHome H2H ODB team at 1-877-546-4311

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.

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.

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.

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

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

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

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

Telehomecare Referral Form

Palliative Registry Referral Form

Palliative Common Referral Form

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

Intake and Linking Referral Form

COVID-19 Remote Self-Monitor Referral Form

Clinic Eligibility