Central area

Instructions

Form provided by the Ministry of Long-Term Care under the Fixing Long-Term Care Act, 2021.

If you wish to be admitted to a long-term care (LTC) home, you must fill out this form. This information is required by Ontario Health atHome, the designated placement co-ordinator for LTC homes, to determine if you are eligible for admission. Ontario Health atHome may collect additional personal health information from your health care providers
for the purpose of determining your eligibility. Ontario Health atHome may also use and disclose the information for the same purpose.

Clinic Eligibility

COVID-19 Remote Self-Monitor Referral Form

Instructions

Formulaire fourni par le ministère des Soins de longue durée en vertu de la Loi de 2021 sur le redressement des soins de longue durée.

Si vous souhaitez être admis dans un foyer de soins de longue durée (SLD), vous devez remplir ce formulaire. Ces renseignements sont requis par Santé à domicile Ontario, le coordonnateur du placement désigné pour les foyers de SLD, afin de déterminer si vous êtes admissible à l’admission. Santé à domicile Ontario peut recueillir d’autres renseignements personnels sur la santé auprès de vos fournisseurs de soins de santé afin de déterminer votre admissibilité. Santé à domicile Ontario peut également utiliser et divulguer les renseignements aux mêmes fins.
Renseignements sur le demandeur

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

Intake and Linking Referral Form

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

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

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.

Palliative Care Resources Guide for Long-Term Care Homes

Palliative Common Referral Form

Palliative Registry Referral Form

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

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

Telehomecare Referral Form