4520 84E

User Manual: 4520

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Completion Instructions for the Request for Prior Approval for Full Payment of Insured

Out-of-Country (OOC) Health Services

INTRODUCTION

All sections of this form must be fully completed and legible.

The form is required to request prior approval for full payment by the ministry for insured OOC hospital/medical services on

behalf of your patient. The ministry does not cover travel and accommodation costs associated with traveling OOC for prior

approved treatment.

Information about the OOC prior approval program and application forms are available on the ministry’s website at:

http://www.health.gov.on.ca/english/providers/forms/form_menus/ohip_prof_fm.html

These forms are available in a ﬁ ll and print format or can be downloaded for completion. Completed forms may be sent to the

ministry by fax: 613 536-3181 or 1 866 221-3536.

PHYSICIAN RESPONSIBILITIES

By signing the application, you, as the attending Ontario doctor, are prescribing a treatment based on your professional

knowledge.

DO NOT COMPLETE THIS FORM IF:

 You do not know the answer to the questions in Parts 5 and 6. In most cases, you will have to research the availability of

current services in Ontario and wait times in several areas of the province.

 The required treatment has already been rendered as services will be ineligible for reimbursement.

 Treatment is required as a result of a work-related accident. Please complete a Health Professional’s Report (Form 8)

and contact the Workplace Safety and Insurance Board (WSIB) at www.wsib.on.ca to discuss coverage. OHIP does not

insure service(s) to which a person is entitled under the Workplace Safety and Insurance Act.

 You are requesting Emergency/911/CritiCall Transfers. If these services are required, please complete the “Application

for Approval of Full Payment of Insured OOC Health Services Emergency/911/CritiCall Transfers Form 4524-84.

 You are requesting Diagnostic Laboratory Testing. If these services are required, please complete the “Request for Prior

Approval for Full Payment of Insured OOC Health Services for Diagnostic Laboratory Testing Form 4521-84.

Full payment of medically necessary hospital/medical services will be authorized only when the proposed OOC treatment or

procedure is:

 performed at a hospital or licensed health facility; and

 not experimental or for research or for a survey; and

 generally accepted by the medical profession in Ontario as appropriate for a person in the same medical circumstances

as the insured person; and

 either not performed in Ontario by an identical or equivalent service; or

 performed in Ontario but the insured person must receive the services outside Canada to avoid a delay that would

result in death or medically signiﬁ cant irreversible tissue damage.

Please ensure that all sections of the form are legible; otherwise, it will be returned by fax asking for clariﬁ cation of the

information.

If you require clariﬁ cation or additional information in order to complete this application form, please call the ministry’s

toll-free number 1 888 359-8807, or send an e-mail inquiry to: OOCPRIORAPPROVALINQ.MOH@ontario.ca

Part 1 - Patient Information

When completing this section, the Ontario physician’s ofﬁ ce should verify that the patient’s health number and address are

current and correct.

If the patient is under the age of 16, the parent or legal guardian must sign on the patient’s behalf.

If the application is signed on behalf of a person over the age of 16 who is not the applicant, documentation must be provided

which establishes that the person signing the form is legally authorized to do so. Acceptable documentation includes, for

example, Power of Attorney for property or personal care.

4520-84E (2015/03) Page 1 of 5

Completion Instructions for the Request for Prior Approval for Full Payment of Insured

Out-of-Country (OOC) Health Services

Part 2 - Referring Ontario Physician

Please provide your name, OHIP billing number and ofﬁ ce address. Please also provide a telephone number where the

ministry can reach you. If your ofﬁ ce telephone does not accept messages, please provide an alternate number such as

your private line.

Part 3 - Proposed OOC Health Facility/Hospital

Please provide the name and address of the OOC treatment facility and the name of the physician or contact person at

this

facility. A preferred provider must be selected if a preferred provider arrangement has been established for the required

service. For a list of preferred provider facilities, please visit the ministry’s website at: http://www.health.gov.on.ca/

english/providers/program/ohip/outofcountry/us_preferred_providers.html

Part 4 - Treatment - General Information

This section must be fully completed and must include the clinical diagnosis in full and the proposed treatment or procedure

for which prior approval is requested. If services will be required on an inpatient basis, please provide the anticipated

number of days and the planned admission date, if known.

If the patient is being referred OOC for an extended period of time, the Ontario physician should also provide the reasons

for the lengthy admission. You are also required to advise if this patient has made a previous attempt to receive this

treatment OOC.

Part 4A - Bariatric Surgery - Treatment Requested

Patients must either be recommended for surgery by a multidisciplinary team at an Ontario Regional Assessment and

Treatment Centre or participate in a multidisciplinary regimen of at least three months duration. If you are applying for

bariatric surgery, please provide your patient’s height, weight, co-morbidities and names of other Ontario health professionals

consulted (attaching relevant consultation notes). Please advise if your patient suffers from any condition that could affect his

or her suitability for surgery. Please also include the speciﬁ c bariatric procedure being requested OOC as not all procedures

are insured.

Parts 4B, 4C, or 4D - Request for Cancer Treatment/Inpatient Residential Treatment/Surgical Procedure

Please complete ONLY the section relating to the OOC service requested, i.e., OOC cancer treatment OR inpatient

residential treatment OR a surgical procedure. Please provide all information requested.

Part 4E - MRI (Magnetic Resonance Imaging) Requested

Please specify the MRI procedure being requested. If you are applying for an open MRI please also explain why your

patient requires this service and include your patient’s height, weight and abdominal girth.

Part 5 - Treatment Availability

This section establishes the need for the patient to be referred outside Canada and all criteria described in the Health

Insurance Act and Regulations must be met for the application to be eligible for approval.

The ﬁ rst two questions establish whether the treatment being requested is appropriate for a person in the same medical

circumstances as the patient and whether the service is performed in Ontario by an identical or equivalent procedure.

The next two questions establish whether the treatment must be performed OOC to avoid a delay which would result in

death or medically signiﬁ cant irreversible tissue damage. At least one of these questions must be answered “yes”. A “no”

answer to each of these questions indicates that there is no urgent need for the patient to go OOC for treatment.

It is expected that the referring Ontario physician will have attempted to ﬁ nd treatment for his/her patient in Ontario and will

provide the names of all health professionals contacted in this regard. There are no geographical limitations described in the

Health Insurance Act relating to the travel distance required to obtain treatment in Ontario.

Part 6 - Follow-up Care

Completion of this section is required to conﬁ rm that the patient’s follow-up care will be provided in Ontario and not by the

OOC physician.

Signatures

This application must be signed and dated by both the patient (or the patient’s authorized representative) and the referring

Ontario physician. If this application has not been signed by the patient, please explain why.

Ministry of Health

and Long-Term Care

4520-84E (2015/03) Page 2 of 5

English Form

Ministry of Health

and Long-Term Care

Request for Prior Approval for Full Payment

of Insured Out-of-Country (OOC) Health Services

AN ATTENDING ONTARIO PHYSICIAN MUST COMPLETE THE ENTIRE FORM.

PRINT CLEARLY TO ENSURE FORM IS LEGIBLE.

Please return to: Health Services Branch, Provider Facility Payment Unit, Out of Country Program, 1055 Princess Street, PO Box 168, Kingston ON K7L 5V1.

Applications may be faxed to 613 536-3181 or 1 866 221-3536. For information or clariﬁ cation regarding this form, please call 1 888 359-8807.

Facility (A preferred provider must be selected if a preferred provider arrangement has been established for the required service.)

Telephone Number

Address (Street number and name, R.R., P.O. Box, General delivery)

Part 3 - Proposed OOC Health Facility/Hospital

Email Address

Last Name

City State/Country Code

Name of:

()

OOC physician Contact person

First Name

Last Name First Name

Ofﬁ ce Address (Street number and name, R.R., P.O. Box, General delivery)

Part 2 - Referring Ontario Physician

Email Address (optional)

Telephone Number where we can reach you

( )

City Province Postal Code Provider Billing Number

Last Name

parent of child under 16 years of age legal guardian attorney under power of attorney other (specify)

Initials

First Name

Current Mailing Address (Street number and name, R.R., P.O. Box, General delivery)

City Province

Telephone Number (Home)

Parent/Legal Guardian’s Last Name (if applicable)

Postal Code

Where this form is signed by a person who is not the applicant, indicate the relationship between the applicant and the person completing the form.

If legal guardian, attorney or other, please provide copy of document which establishes that status or provide a consent signed by the patient permitting you to

apply and communicate with the ministry on behalf of the patient if form is signed on behalf of person over the age of 16.

Version Code

Date of Birth

Year Month Day Sex

Part 1 - Patient

Health Number

Parent/Legal Guardian’s First Name (if applicable)

()

ExtensionTelephone Number (Business/Daytime)

()

Extension Fax Number

()

Extension Fax Number

()

Day

For Ministry use only

Date rec’d

Reference Number

Year Month Day

If yes, DO NOT complete this form. Please complete a Health Professional’s Report (Form 8) and contact the Workplace Safety and Insurance Board (WSIB).

Is the OOC treatment required as a result of a work-related accident? Yes No

Male Female

Cancer Treatment Surgical Procedure Bariatric Surgery Inpatient Residential Treatment

Other Services (MRI, CT, Consultation) (specify)

Disponible en français4520-84E (2015/03) Page 3 of 5

Clear Form

Instructions

Part 4A - Bariatric Surgery - Treatment Requested

Names of all other Ontario physicians (including specialists) consulted in the past 6-12 months concerning the co-morbid conditions listed above (attach list if

necessary). Please attach copies of all relevant documentation and consultation letters.

Does your patient currently suffer from any condition (such as depression or cardiovascular disease) that could affect his or her suitability for surgery? Please explain.

Specify bariatric procedure for which prior approval is requested (Note: some bariatric procedures are not insured.)

In addition to general information completed in Part 4 above:

Patient’s height: Patient’s current weight:

Patient’s co-morbid conditions (attach copies of relevant documentation)

Please () whether the application is for:

Clinical Diagnosis (condition for which treatment is sought):

Proposed treatment and/or procedure for which prior approval is requested:

Have you previously requested and/or obtained this service out of the country?

Please advise the date and/or facility, city, state/country and provide reason for reapplication:

No. of days anticipated for hospitalization

Date of OOC consultation (if applicable) Date of surgeryProvide anticipated admission date

Year Month Day Year Month DayYear Month Day

If this request is for substance abuse or mental health treatment, provide the name of the referral agent contacted at ConnexOntario’s Drug and Alcohol Registry of

Treatment (DART), 1 800 565-8603.

If this request is for treatment of an eating disorder, provide the name of the referral agent contacted at ConnexOntario’s Mental Health Service Information

1 866 531-2600 or the Provincial Network of Eating Disorder Service Providers in Ontario.

Part 4C - Inpatient Residential Treatment Requested

In addition to general information completed in Part 4 above:

Part 4D - Surgical Procedure Requested

In addition to general information completed in Part 4 above:

Inpatient Services Outpatient Services

Has OOC treatment already been received without ministry approval?

ft in. cm lb kg

Year Month Day

Names of all other Ontario physicians (including specialists) consulted in the past 6-12 months concerning this condition listed above (attach list if necessary).

Please attach copies of all relevant documentation and consultation letters.

Names of all other Ontario physicians (including specialists) consulted in the past 6-12 months concerning this condition listed above (attach list if necessary).

Please attach copies of all relevant documentation and consultation letters.

Part 4B - Cancer Treatment Requested

Please () whether the application is for:

Surgery Radiation Chemotherapy (specify)

Names of all other Ontario physicians (including specialists contacted at the nearest Regional Cancer Centre) consulted in the past 6-12 months concerning this

condition listed above (attach list if necessary). Please attach copies of all relevant documentation and consultation letters.

In addition to general information completed in Part 4 above:

No Yes (If yes, please provide date.)

Part 4 - Treatment - General Information

Part 4E - MRI (Magnetic Resonance Imaging) Requested

Please () whether the application is:

Patient’s height: Weight:

ft lb Abdominal girth: cm in. kg cm in.

If no, please arrange for your patient

to be assessed in Ontario.

No Yes

with contrast without contrast with and without contrast

open (explain why and provide the following information)

Has your patient been assessed by an Ontario Bariatric Regional Assessment and Treatment Centre? Yes No

Diagnostic Code

If this request is for cardiac care treatment, provide the name of the person contacted at the Cardiac Care Network of Ontario, 416 512-7472.

4520-84E (2015/03) Page 4 of 5

Part 6 - Follow-Up Care

All accompanying documents will be considered as part of this application. I understand that the MOHLTC or its agents may collect, use or

disclose personal health information and/or records relating to this application for the purposes of the administration of the Health Insurance

Act including the administration of the OOC program. I understand that this may involve disclosure of personal health information and/or

records related to any health care providers, institutions and agencies that require it as determined necessary by OHIP. Collection of any of this

information is authorized by section 4.1 of the Health Insurance Act. For information about MOHLTC collection practices, see our website at

http://www.health.gov.on.ca/english/public/legislation/bill_31/stat_info_practices.pdf.

Please provide details if this treatment is not performed in Ontario (include names of physicians and/or health facilities contacted in Ontario to determine whether

treatment is performed):

Is this treatment generally accepted in Ontario as appropriate for a person in these medical circumstances?

Is this treatment performed in Ontario by an identical or equivalent procedure?

If “yes”, where is this service performed in Ontario?

Email address

Part 5 - Treatment Availability

Is this treatment required out of Canada to avoid a delay in obtaining the treatment in Ontario that would:

A) Result in death? B) Result in medically signiﬁ cant irreversible tissue damage?

If tissue damage is reasonably expected to result from delay, describe the type of damage:

If “yes” to either of the above, how soon is the treatment required?

Name of physician(s) contacted to determine availability of treatment:

Estimated length of waiting period in Ontario:

For patients requiring ongoing long-term care, please provide details relative to your short and long-term plans for follow up care to be provided in Ontario should

payment for out-of-country treatment be approved:

NOTE: Written approval must be received from the ministry before OOC health services are rendered. OHIP does not pay for ambulance services,

transportation costs, or out-of-hospital food, accommodation, drugs or prescriptions, including take-home prescriptions.

IT IS AN OFFENCE TO KNOWINGLY GIVE FALSE INFORMATION TO THE ONTARIO HEALTH INSURANCE PLAN IN ANY APPLICATION OR STATEMENT

MADE TO THE PLAN.

I hereby declare the information provided by me to be true.

Signature of Referring Physician Date (yyyy/mm/dd)

Relationship to Patient (if not signed by patient)

Please explain why form has not been signed by patient:

Name of Patient or Parent/Guardian (print or type)

Signature of Patient or Parent/Guardian Date (yyyy/mm/dd)

Yes No

Weeks / Months

Yes No

If treatment is not available in Ontario:

Is this treatment generally accepted in Ontario as appropriate for a person in these medical circumstances?

Is this treatment generally accepted as experimental in Ontario?

Is this treatment performed in Ontario by an identical or equivalent procedure?

4520-84E (2015/03) Page 5 of 5

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4520 84E

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