Erie St. Clair 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.

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

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

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

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.

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

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

Erie Shores HealthCare outpatient referral and treatment form – fillable

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

Windsor Regional Hospital – Met Campus 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

Symptom Response Kit (SRK) Request Order Form Windsor

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

Providers cupboard usage order form – fillable

Referral and treatment plan form – fillable

Medical update request form – wound

Medical update request form

Erie Shores HealthCare emergency referral and treatment form – fillable

Offloading assessment form – fillable

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

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

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

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

Bluewater Water Health inpatient referral and treatment form – fillable

Bluewater Water Health outpatient referral and treatment form – fillable

Bluewater Water Health emergency referral and treatment form – fillable

Assessment service plan form – fillable

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

Walker assessment eligibility 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.

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

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

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

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

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

Referral and treatment plan pain medication order form – fillable

Total contact casting treatment and assessment forms – fillable

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