Forms

Effective October 2026
Tel: 905-855-9090 / 1-877-336-9090
Fax: 905-855-8989 / 1-877-298-8989
Send to OHaH MH HPG Central Ordering Inbox

Please fax this form to: 1 888 499 0555
To contact the ESC Ontario Health atHome call: 1-833-515-1234

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.

To be used by all Service Provider Organizations (SPOs) when transferring care.
For personal support: PSS Supervisor to complete form to hand over care to new PSS provider

Service Provider Organizations are required to complete the following referral when referring a patient to Ontario Health
atHome. With this referral, please include assessment information (most recent interRAI HC/CA), updated medical
orders, PSW/nursing/therapy assessments and substitute decision maker (SDM) documentation.

Form # PSR003
Please Note: This form needs to be faxed after sending the referral in Resource Matching and e-Referral (RM&R)

MHRH Fax: (905) 707-241

Please Note: This form needs to be faxed after sending the referral in Resource Matching and e-Referral (RM&R)
Signed Physician/NP Medical Orders are not required for Occupational Therapy, Personal Support and Physiotherapy

Form # PSR003 – Oak Valley Hospital
Please Note: This form needs to be faxed after sending the referral in Resource Matching and e-Referral (RM&R)

Please Note: This form needs to be faxed after sending the referral in Resource Matching and e-Referral (RM&R)
Signed Physician/NP Medical Orders are not required for Occupational Therapy, Personal Support and Physiotherapy

*Requests are only for 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 Humber River Hospital

For Humber River Hospital
Phone: 416-242-1000 x 21500
Fax: 416-242-1068

Form #PSR003 – Humber River Hospital
Please Note: This form needs to be faxed after sending the referral in Resource Matching and e-Referral (RM&R)

* Complete medical orders for PICC line or Port Flush
For Humber River Hospital

* Complete medical orders for PICC line or Port Flush
For Humber River Hospital

* Complete medical orders for PICC line or Port Flush
For Humber River Hospital

* Complete medical orders for PICC line or Port Flush
For Humber River Hospital

Form #PSR003 – Humber River Hospital
Please Note: This form needs to be faxed after sending the referral in Resource Matching and e-Referral (RM&R)

Form #PSR003 – Humber River Hospital
Please Note: This form needs to be faxed after sending the referral in Resource Matching and e-Referral (RM&R)

Form #PSR003 – Humber River Hospital
Please Note: This form needs to be faxed after sending the referral in Resource Matching and e-Referral (RM&R)

Form #PSR003 – Humber River Hospital
Please Note: This form needs to be faxed after sending the referral in Resource Matching and e-Referral (RM&R)

Form #PSR003 – Humber River Hospital
Please Note: This form needs to be faxed after sending the referral in Resource Matching and e-Referral (RM&R)

Form #PSR003 – Humber River Hospital
Please Note: This form needs to be faxed after sending the referral in Resource Matching and e-Referral (RM&R)

Please Note: This form needs to be faxed after sending the referral in Resource Matching and e-Referral (RM&R)

For Southlake only
Please Note: This form needs to be faxed after sending the referral in Resource Matching and e-Referral (RM&R)
Signed Physician Medical Orders are not required for Occupational Therapy, Personal Support and Physiotherapy

A School Board Consultant’s report and signature are required from school boards that have Occupational Therapy/Physiotherapy/Speech Language Pathology consultants.
Phone: 416-222-2241 or 905-895-1240 or 1-888-470-2222
Fax: 416-222-6517 or 905-952-2404
*Incomplete referrals will NOT be processed

Office Location: North East
Tel: 1-800-461-2919 / Toll FreeFax: 1-855-697-7358
*Hospital: Use hospital Ontario Health atHome fax number

This form is to be used for the submission of requests for additions, changes, or considerations related to the Ontario Health atHome Medical Equipment and Supplies (MES) Formulary. Submissions may include requests for new products, product substitutions, or other formulary updates. Information collected through this form supports standardized review and decision-making based on clinical evidence, patient need, supply chain resilience and fiscal responsibility. Completed forms must be submitted to the MESModernization@ontariohealthathome.ca for review.

Please fax referral form(s) to: 613-650-2909
For inquiries, contact Ontario Health atHome: 1-833-515-1234 ext. 6244

Monday – Friday 08:30 – 16:30
Campbellford Memorial Hospital Fax: 844-631-5800
Haliburton Highlands Health Services Fax: 844-709-3779
Northumberland Hills Hospital Fax: 844-631-5801
Lakeridge Health Bowmanville Fax: 844-631-5802
Lakeridge Health Oshawa Fax: 905-444-2516
Lakeridge Health Port Perry Fax: 844-631-5803
Markham Stouffville Uxbridge Fax: 844-631-5803
Ontario Shores Fax: 844-631-5803
Peterborough Regional Health Centre Fax: 855-444-9628
Scarborough Health Network The Scarborough Hospital – Birchmount Site Fax: 844-631-5804
Scarborough Health Network – General Campus Fax: 844-631-5805
Ross Memorial Hospital Fax: 844-631-5806
Scarborough Health Network – Centenary Site Fax: 844-631-5808
Lakeridge Health – Ajax/Pickering Fax: 905-444-2524
Whitby Hospital Fax: 905-665-2405

Fax completed form to: 905-855-8989 / 1-877-298-8989

*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

Confirmation of medical stability and program readiness
Inpatient rehabilitative care and other complex continuing care
Do NOT use this application for Palliative care referrals.

…

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.

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.

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.
All Community Referrals, Including Primary Care Providers: Please fax all community referrals to Intake and Extended Hours teams
Fax Number for All
1-866-655-6402
For hospital-based referrals, please fax directly to the appropriate Ontario Health atHome hospital officeFor hospital-based referrals, please fax directly to the appropriate Ontario Health atHome hospital office

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.
All Community Referrals, Including Primary Care Providers:
Please fax all community referrals to Intake and Extended Hours teams
Fax Number for All 1-866-655-6402
For hospital-based referrals, please fax directly to the appropriate Ontario Health atHome hospital office

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.

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.

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.

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

Pediatric Patients at McMaster Children’s Hospital (MCH) Hamilton
Toll Free Phone Number: 1-800-810-0000
All Community Referrals, Including Primary Care Providers: please fax all community referrals to Intake and Extended Hours teams. Fax Number for All:
1-866-655-6402
For hospital-based referrals, please fax directly to the appropriate Ontario Health atHome hospital office listed in page 2 of this form

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.

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

Form 550 B – Fax Completed form to 519-742-0635

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: 1-855-697-7358

*Hospital: Use hospital Ontario Health atHome fax number

Effective September 1, 2026
Fax: 1-855-697-7358

*Hospital: Use hospital Ontario Health atHome fax number

Effective September 2026
Fax: 1-855-697-7358 /Print to NE-Regional E&S
*Hospital: Use hospital Ontario Health atHome fax number

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

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.

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

Last Update: May 2026
Fax: 1-855-697-7358

*Hospital: Use hospital Ontario Health atHome fax number

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.

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

Parenteral Nutrition Order (Adult or Pediatric)
Complete and fax to Ontario Health atHome at 1-519-472-4045 or 1-855-223-2847
Orders are processed between 8:00 am – 8:00 pm (7days/week). Please allow 48 hours for orders to be processed. Referral form must be completed in full to permit processing. Incomplete orders will be returned.

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

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

*Hospital: Use hospital Ontario Health atHome fax number

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

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

Wound Care and General Supply Order Form for Central West area

Urinary Continence Supply Order Form for Central West area

Respiratory Therapy Supply Order Form for Central West area

Ostomy Supply Order Form for Central West area

Infusion and Enteral Supplies Order Form for Central West area

Incomplete referrals will be returned to the referral source with direction for completion
For urgent admissions to Parkwood Palliative Care Unit (PCU), please fax to 519-685-4804 and to the appropriate Ontario Health atHome number noted above.

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

To refer a patient to (apply for) hospice and hospice-type services at: Emmanuel House, Carpenter House, Hospice Niagara McNally House, Dr. Bob Kemp Stedman Margaret’s Place

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.

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

*Hospital: Use hospital Ontario Health atHome fax number

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

Windsor Regional Hospital – Met Campus 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.

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.

Note: This revised form will be effective as of September 2026.

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. 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.

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: 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.

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

The Hamilton Palliative Care Outreach Team (PCOT) is a group of specialist providers from multiple organizations who practice as an interprofessional team.
Eligibility Criteria:
Patients, along with their families/caregivers, are eligible for the Palliative Care Outreach Team services if they meet most of the following criteria:
• Live in the Greater Hamilton area
• Diagnosed with a life-limiting progressive disease
• Complex symptoms
• Meets the Gold Standard Framework “surprise” question:
o Would you be surprised if this person were to die within the next 12 months?
o Are there general signs of decline?
• Complex needs (e.g., social determinants of health)
• Challenges with goals of care discussions/care planning
• Declining functional status
• Complex or potentially complex psychosocial/spiritual needs for the patient and/or family/caregiver

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

Cupboard Usage (Provider and Flex Clinics)
Please Submit This Order Through HPG To Supplies Chatham: 519-351-7080 Ext. 7400

Best practice/evidenced based practice will be initiated unless otherwise written. Wound care outside of evidenced based practice may not be eligible for Ontario Health atHome services. Treatment will be taught and service reduced when appropriate.

Medical update request form – wound

Physician use only. Applicable billing as outlined in the Schedule of Benefits for Physician Services under the Health Insurance Act.

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.

Medical Order Form
Care and Maintenance of Midline Catheter – Contact Ontario Health atHome at 1-800-810-0000

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

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.

Medical Order for the Administration of Influenza Vaccine

Contact Ontario Health atHome at 1-800-810-0000

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

Complete the Burlington PCOT 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

To order Milrinone Infusion Therapy for adult patients

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

Serving the Haldimand, Norfolk, Brant, Brantford, Six Nations and Mississaugas of the Credit First Nations
For Stedman & Six Nations Outreach Team (all areas) – Fax: 519-751-7527
For OHaH Nurse Practitioners (Haldimand and Norfolk areas only) – Fax: 1-833-305-1947
For Norfolk Haldimand Community Hospice – Fax: 519-751-7527

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.

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 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 for teaching of IV Administration
• Speech Language Pathology for Swallowing Assessment

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

For patients being discharged home from hospital with a new tracheostomy and laryngectomy care for patients being discharged home from hospital
Contact the Ontario Health atHome at 1-800-810-0000

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

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

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.

To clearly communicate a patient’s plan of care relating to the provision of CPR.
A copy of this form is to be kept with the patient and a copy is to be sent to the Ontario Health atHome and
shared with all service providers. This plan of treatment can be reviewed and revoked at any time.

To identify who will complete pronouncement and certification of death for an expected death at home
Contact Ontario Health atHome at 1-800-810-0000

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.

Completed by a Primary Care Physician or Registered Dietician

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

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).

Information sheet for patients and families.

Form 550A – Fax completed form to 519-742-0635
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.

South West MAID referral form

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.

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.

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

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

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.

For 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

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.

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

To order care relating to Home Parenteral Nutrition in the South East. NOTE: Minimum 48-72 hours notice required.

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.

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

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

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

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

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.

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

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

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.

Request for Type 1 Diabetes Treatment Order

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 **

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.

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

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

Central East Medical Assistance in Dying Prescription Order Form

Mississauga Halton Symptom Relief Kit Prescription/Order Form.
After signing for one opiate & signing RX, fax this form to Ontario Health atHome Mississauga Office 905-855-8989. Supplies are enough for short-term use (12-24 hours) ONLY. Please write a prescription with ongoing orders for ANY medication expired or needing refills.

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

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

Mental Health and Addictions Nursing Program Referral Form

Mental Health and Addictions Nursing program referrals from hospitals

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

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

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

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

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

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.

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

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

Central West – Hospital Medical Referral Form

A Symptom Relief Kit is to provide emergency symptom management at the end of life (prognosis of 3 months or less). The kit will provide a small amount of frequently used medication intended to treat common symptoms that occur at the end of life.
Please fax back to ontario health athome 705‐792‐6270

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

Please fax to: 613.745.8243 or 1.855.450.8569
Information contained in this form is private and confidential, intended only for the named recipient(s).
If you received this in error, please notify the sender by phone immediately and secure the information until the sender provides you with more direction. Do not copy or disclose this information to anyone else.

Completed by Retirement Home staff when requesting a Swallowing Assessment

Community Medical Referral Form – Central West

This form is NOT to be used for requesting Patient Health Records
Freedom of Information Request Form
Under the Freedom of Information and Protection of Privacy Act

Please Note: A $5.00 application fee is required for all access requests.

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

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)

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.

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.

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.

Referral Form for Ontario Health atHome

Telehomecare COPD and Heart Failure Referral Form

Adult Speech Language Pathology Referral Form

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.

Referral Form for Ontario Health atHome For Community Referrals
Eligibility for Direct Services: Valid OHIP card; Assessment by a Health Care Professional.
Fax Form to 613.745.6984 or 1.855.450.8569

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

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.

Authorization for Release of Personal Health Information 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.

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.

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

Narcotic Infusion Therapy Referral Form

Hospital Request for Assessment Form

Hospital Narcotic Infusion Therapy Referral Form

Hospital Infusion Therapy Referral Form

Hip and Knee Referral 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.

Community Paramedicine Referral Form

* All sections must be completed – incomplete forms will be faxed back to the referral source
Please FAX referral to 807-346-4484

Palliative Symptom Management Kit Order Form, North West

This Ontario Health atHome Services form is a communication tool between the Ontario Health atHome and the patient’s primary care provider.

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.

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

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

Mental Health and Addictions Nursing Program Referral Form

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

Referral for Ontario Health atHome Services in North East.

Fax to: Kirkland Lake: 705 567 9407
North Bay: 705 474 0080
Parry Sound: 1 855 773 4056
Sault Ste. Marie: 705 949 1663
Sudbury: 705 522 3855
Timmins: 705 267 7795

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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

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

Eligibility for Telehomecare Services
– Patient has an established diagnosis of Heart Failure or COPD (with or without co-morbid conditions).
– Patient has a fixed address and a phone.
– The patient is capable of managing monitoring equipment (BP and O2 monitors, scale). The patient is able to read and answer questions (yes/no multiple choice) using a computer tablet.
– Patient meets criteria for Virtual COPD clinic (CONFIRMED diagnosis of COPD with exacerbations leading to ED visit or hospitalization)

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

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

Prescription form for Symptom Management Kit

Central West Palliative Nurse Practitioner Referral Form

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

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

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

Completed by a Primary Care Physician

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

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”

ELIGIBILITY FOR TELEHOMECARE SERVICES

• Patient has an established diagnosis of Heart Failure or COPD (with or without co-morbid conditions).
• Health care provider feels the patient will benefit from Telehomecare. (This would require the patient or caregiver being able to operate simple equipment.)
• Patient lives in a residential setting with an active land line (internet or analog phone line).
• Patient or family caregiver is able to provide informed consent to participate.

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

With extended evening and weekend hours, and seven convenient locations to choose from, for most patients Ontario Health atHome community clinics are the best options to ensure high-quality, specialized nursing that meets their care need.

Medical Orders Best practice/evidenced based practice will be initiated unless otherwise written. Wound care outside of evidenced based practice may not be eligible for Ontario Health atHome services. Treatment will be taught and service reduced when appropriate.

North Simcoe Muskoka Medical Referral Form Adult

Ontario Health atHome MAiD Care Coordination service is providing this form to the Primary Care Provider to assist in the effective referral of a patient who has expressed interest in MAiD.

Please fax referral forms to: 705-792-6270
If required, Telehomecare staff will fax the referral form for existing patients to the Primary Care Provider to verify and/or provide any relevant information.

Common Palliative Referral Guidelines

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.

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

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

South East Medical Assistance in Dying Procedural Record

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.

Home and Community Care Support Services South East Medical Order Form

Palliative Care SBAR Communication Tool for Nurses in the South East

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