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Physician Forms

For Physicians and Primary Care Providers: Link your patients to Home and Community Care Support Services, and other health programs and services. Our Care Coordinators are specialists in assessing and finding ways to meet patients' home and community care needs. We link patients to an extensive array of care services, including specialized nursing, palliative nurse practitioners, rapid response nurses to assist with hospital-to-home transitions, occupational therapists, physiotherapists, personal support workers and more.

Our Primary Care Hotline makes it easy to connect with one of our Care Coordinators.

  • Phone:  416-222-2241 or 1-888-470-2222 (Press 1, then press 4 to speak to a Care Coordinator) 
  • Fax:  416-222-6517 or 905-952-2404

REFERRAL FORMS

These forms are to be completed and signed by physicians and primary care provoders in the community who wish to refer patients to Home and Community Care Support Services.

OHIP Billing Code information is noted further below. 

  1. Intake and Linking Referral Form – Refer a patient to our services. 
  2. Medical Referral Form – Use this form if your referral includes medical/treatment orders. Our services include specialized nursing (including care at our community nursing clinics, palliative nurse practitioners, rapid response nurses to assist with hospital-to-home transitions), occupational therapists, physiotherapists and more. 
  3. COVID-19 Remote Self-Monitoring Program 
  4. Palliative Care Common Referral Form – Use this form to refer a patient for palliative care services at home or in the community.
  5. Palliative Symptom Relief Kit Prescription – Use this form if your referral includes medical orders for a palliative patient at end of life. 
  6. Palliative Patient Registry Referral Form – Use this form to have a patient added to the palliative patient registry.  This program supports patients who suffer life-limiting illness and predicted to be in their last year of life.
  7. Telehomecare Referral Form – Support for patients with mild to moderate Chronic Obstructive Pulmonary Disease (COPD) or Congestive Heart Failure (CHF) through remote health monitoring and coaching. Referrals and consultations are covered by OHIP. Read this fact sheet prior to referring patients.

Please ensure these referral form(s) are completed as fully as possible to avoid any delays in activating the requested services.

ADDITIONAL RESOURCES

  • Learn about Home and Community Care Support Services – 11 minute video
  • Learn about Long-Term Care Application & Placement Process – 24 minute video
  • Community Nursing Clinics Fact Sheet - Our community nursing clinics offer wound care, post-surgical care, IV treatment and other specialized nursing services. Our clinics are located across North York, York Region and South Simcoe. Visits are by appointment only, offering quick and easy access to nursing care for patients recovering from illnesses, accidents and surgeries. For more information read our Clinic Eligibility fact sheet. To refer your patient to one of our Home and Community Care Support Services community clinics, please fill out our Medical Referral Form.
  • Health Care Connect – Helps link primary care providers with unattached patients in their communities. To reach a Care Connector, call 1-888-470-2222, ext. 6181, or email mailto:HealthCareConnect@lhins.on.ca.
  • Palliative Early Identification and Prognostic Indicator Guide – This tool aims to help family physicians, specialist physicians and nurse practitioners in earlier identification of patients nearing the end of life who could benefit from a hospice palliative care approach to care.
  • Telehomecare Fact Sheet – This six-month program links patients with COPD or heart failure with RNs who provide remote monitoring and health coaching.  

OHIP BILLING CODES

  • Long-Term Care Application - Code K038 - The service rendered by the most responsible physician for the completion and submission of a Long-Term Care Health Assessment Form on behalf of a patient for whom the physician provides on-going medical care. The amount payable for completion of the Long-Term Care Health Assessment Form if completed, in whole or in part, by a person other than the physician is nil. 
  • Home Care Application - Code K070 - The service rendered by the most responsible physician for completion and submission of a home care service request form on behalf of a patient for whom the physician provides on-going medical care. The amount payable for this service is in addition to the assessment fee payable, where applicable. The amount payable for completion of the home care service request form if completed in whole or in part by a person other than the physician or the physician's employee is nil. 
  • Home Care Supervision - K071 & K072 & K124 - The service rendered by the most responsible physician for personally providing medical advice, direction or information to health care staff of home and community care or home and community care contractor on behalf of a patient for whom the physician provides on-going medical care. The date, question, response and identity of the health care staff must be recorded in the patient's medical record. The amount payable for home care supervision without the required record of service in the patient's medical record is nil. The amount payable for home care supervision rendered on the same day as a consultation or visit by the same physician with the same patient is nil. 
    • K071 for Acute home care supervision (maximum 1 every week for the first 8 weeks following admission to home care program)
    • K072 for Chronic home care supervision (maximum 2 per month commencing in the 9th week following admission to the home care program) K124 for a case conference regarding a home and community care patient. 
    • K124 requires participation by the physician most responsible for the care of the patient and at least two other participants that include physicians, regulated social workers, employees of home and community care support services and/or regulated health professionals. 

*Schedule of Benefits for Physician Services under the Health Insurance Act.