Champlain area
We are now Ontario Health atHome (opens in a new tab) , a single organization coordinating local home and community care, long-term care placement and help finding services in the community. Our name has changed but our services remain the same. Patients continue to work with the same patient care teams and can contact us the same way.
Information and Referral
310-2222
Toll-free:1-800-538-0520
Fax:613-745-6984
TTY:711
To request home and community care services, please complete this online referral form, or call us at 1-800-538-0520 (toll-free) or 613-745-5525.
Champlain Area Office Locations
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Ottawa
4200 Labelle St,
Suite 100
Ottawa, ON, K1J 1J8
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Bell’s Corners
301 Moodie Dr.
Suite 105
Ottawa, ON, K2H 9C4
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Cornwall
709 Cotton Mill St.
Cornwall, ON, K6H 7K7
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Hawkesbury
119 Main St. East
Suite 101
Hawkesbury, ON, K6A 1A1
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Pembroke
1100 Pembroke St. East
Pembroke, ON, K8A 6Y7
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Renfrew
850 O’Brien Rd.
Unit 8
Renfrew, ON, K7V 3Z4
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Winchester
530 Fred St.
Suite D, PO Box 209
Winchester, ON, K0C 2K0
Compliments and Concerns?
Please share your feedback with your care coordinator. You may also share compliments or concerns in the following ways:
Email: Quality-Champlain@ontariohealthathome.ca
Phone: 1-844-454-1322
Newsroom and Media Relations
Visit our newsroom for more information on news and events.
For all media-related enquiries, please contact media@ontariohealthathome.ca.
For non-media-related enquiries, please visit the Contact Us page to access additional contact information.
Accessibility Documents
Forms
Title | Summary | Region | Last Modified | Category | File Type | File Size | Link | hf:doc_tags | hf:doc_categories | hf:file_type |
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Application for Determination of Eligibility for LTC – English | Application for Determination of Eligibility for Long-Term Care – English | Champlain | January 9, 2023 | Forms | 250 KB | champlain | forms | |||
Authorization for Release of Personal Health Information Form | Authorization for Release of Personal Health Information Form | Champlain | September 19, 2022 | Forms | 522 KB | champlain | forms | |||
Caregiver Distress Program-EN | What is the Caregiver Distress Respite Program? | Champlain | June 28, 2024 | Forms | 209 KB | champlain | forms | |||
Community IV Therapy Venous Access Algorithm | Community IV Therapy Venous Access Algorithm | Champlain | September 19, 2022 | Forms | 118 KB | champlain | forms | |||
Consentement à l’utilisation du courriel | un moyen facile et pratique pour nos patients, mandataires spéciaux ou fondés de pouvoir de communiquer avec le coordonnateur de soins et le Santé à domicile Ontario. | Champlain | July 8, 2024 | Forms | 289 KB | champlain | forms | |||
Convalescent Care Program-EN | What is Convalescent Care? | Champlain | June 28, 2024 | Forms | 242 KB | champlain | forms | |||
Court séjour provisoire, Liste de choix de foyers de soins de longue durée | Champlain – Court séjour provisoire, Liste de choix de foyers de soins de longue durée | Champlain | July 8, 2024 | Forms | 361 KB | champlain | forms | |||
Demande de détermination d’admissibilité pour une admission en foyer de soins de longue durée | Demande de détermination d’admissibilité pour une admission en foyer de soins de longue durée | Champlain | September 21, 2022 | Forms | 33 KB | champlain | forms | |||
Email Consent and Use Form | Email offers an easy and convenient way for our patients, their Substitute Decision Makers (SDM) or those appointed with Powers of Attorney (POA) to communicate with their Care Coordinator and Ontario Health atHome. | Champlain | July 8, 2024 | Forms | 278 KB | champlain | forms | |||
First Dose Parenteral Administration Form | First Dose Parenteral Administration Screener and Medical Referral to be faxed to Ontario Health atHome (before 12pm for same day administration to be arranged) with completed information in order for first dose administration of parenteral medication to be considered: | Champlain | July 8, 2024 | Forms | 216 KB | champlain | forms | |||
Formulaire de demande pour la divulgation de renseignements personnels | 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 | Central, Central East, Central West, Champlain, Erie St. Clair, Global, Hamilton Niagara Haldimand Brant, Mississauga Halton, North East, North Simcoe Muskoka, North West, South East, South West, Toronto Central, Waterloo Wellington | September 19, 2024 | Forms | 229 KB | central central-east central-west champlain erie-st-clair global hamilton-niagara-haldimand-brant mississauga-halton north-east north-simcoe-muskoka north-west south-east south-west toronto-central waterloo-wellington | forms | |||
Formulaire de référence à l’équipe régionale de consultation en soins palliatifs de Champlain | L’Équipe régionale de consultation en soins palliatifs de Champlain est là pour vous appuyer. | Champlain | September 5, 2024 | Forms | 336 KB | champlain | forms | |||
Health Assessment – Ontario Health atHome | 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. | Champlain, Global | October 25, 2024 | Forms | 2 MB | champlain global | forms | |||
Infusion Therapy – IV Remdesivir Referral Form | – Patients will receive treatment in our community nursing clinics, unless under exceptional circumstances. | Champlain | July 5, 2024 | Forms | 267 KB | champlain | forms | |||
Infusion Therapy Venous Access Referral 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. | Champlain | July 9, 2024 | Forms | 148 KB | champlain | forms | |||
Integrated Bruyere Outpatient and Community Stroke Rehabilitation Referral Form | Integrated Bruyere Outpatient and Community Stroke Rehabilitation Referral Form. Complete and fax to 613-745-8243 | Champlain | July 8, 2024 | Forms | 275 KB | champlain | forms | |||
Le programme de soins de relève de courte durée, Soins de relève de courte liste de vérification vérification des conseils | Le programme de soins de relève de courte durée offert dans des foyers de soins de longue durée comprend des caractéristiques importantes que les participants ou leur représentant doivent comprendre. Lors de la consultation, le coordonnateur de soins suit la présente liste de vérification afin de s’assurer que le patient capable, le procureur ou le mandataire spécial comprenne bien en quoi consiste le programme. | Champlain | July 11, 2024 | Forms | 1,016 KB | champlain | forms | |||
Liste de choix de foyers de soins de longue durée | Champlain, Liste de choix de foyers de soins de longue durée | Champlain | July 8, 2024 | Forms | 546 KB | champlain | forms | |||
Liste de vérification pour les patients hospitalisés – Renseignements sur les soins de longue durée | La présente liste de vérification a pour but d’assurer que le coordonnateur de soins fournit des conseils au patient, au procureur, ou au mandataire spécial au sujet des plus importants facteurs liés au placement du patient dans un foyer de soins de longue durée. Toutes les déclarations cochées ci-dessous s’appliquent à la situation du patient. | Champlain | July 8, 2024 | Forms | 338 KB | champlain | forms | |||
Long-term Care Counselling Checklist for Community Patients | The purpose of this checklist is to ensure the patient – or power of attorney (POA), or substitute decisionmaker (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, below, applies to the patient’s situation. | Champlain | July 5, 2024 | Forms | 179 KB | champlain | forms | |||
Long-Term Care Counselling Checklist for Hospital Patients | 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. | Champlain | July 5, 2024 | Forms | 337 KB | champlain | forms | |||
Long-Term Care Home Crisis Choice List – Bilingual | Long-Term Care Home Crisis Choice List | Choix des foyers de soins de longue durée en cas de Crise | Champlain | July 8, 2024 | Forms | 515 KB | champlain | forms | |||
Long-Term Care Home Choice List | Champlain Long-Term Care Home Choice List | Champlain | July 8, 2024 | Forms | 516 KB | champlain | forms | |||
Long-Term Care Home Short Stay Interim Choice List – English | Please select up to five long-term care homes (LTCHs) for short-stay interim and rank them in order of your preference. The applicant’s name will be added to the wait lists for the chosen homes if eligible and if the chosen LTCHs can provide the required care. Ontario Health atHome will notify you about eligibility. Short-stay interim beds are available to all hospital ALC-LTC patients. | Champlain | July 8, 2024 | Forms | 303 KB | champlain | forms | |||
Long-Term Care Home Short-Stay Respite Choice List | Please select up to five long-term care homes (LTCHs) for short-stay respite, including any out-of-Champlain choices and rank them in order of your preference. The applicant’s name will be added to the wait lists for the chosen homes if eligible and if the chosen LTCHs can provide the required care. Ontario Health atHome will confirm with you the availability of the requested dates. | Champlain | July 8, 2024 | Forms | 382 KB | champlain | forms | |||
Medical Referral Form | Orders are fulfilled per Community Protocols documented on page 2, unless physician requests otherwise. We process only completed referrals | Champlain | July 9, 2024 | Forms | 123 KB | champlain | forms | |||
Medical Referral Infusions Pain and Symptom Management | 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. | Champlain | July 9, 2024 | Forms | 1 MB | champlain | forms | |||
Negative Pressure Wound Therapy Referral Form | 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. | Champlain | August 15, 2024 | Forms | 580 KB | champlain | forms | |||
Patients dans la communauté – Liste de vérification des conseils pour admission en soins de longue durée | Le présent document a pour but d’assurer que le coordonnateur de soins fournit des conseils au patient, procureur ou mandataire spécial sur les plus importants facteurs du placement dans un foyer de soins de longue durée (FSLD). Toutes les déclarations cochées cidessous s’appliquent à la situation du patient. | Champlain | July 5, 2024 | Forms | 182 KB | champlain | forms | |||
Programme de relève et de réduction de la détresse des soignants | Qu’est-ce que le Programme de relève et de réduction de la détresse des soignants? | Champlain | July 18, 2024 | Forms | 216 KB | champlain | forms | |||
Programme de soins de convalescence | Que sont les soins de convalescence? | Champlain | August 6, 2024 | Forms | 248 KB | champlain | forms | |||
Referral Form for Community Referrals | Champlain Referral Form for Community Referrals | Champlain | June 29, 2024 | Forms | 108 KB | champlain | forms | |||
Regional Palliative Consultation Team Referral Form | The Champlain Regional Palliative Consultation Team (RPCT) is here for you. | Champlain | September 5, 2024 | Forms | 383 KB | champlain | forms | |||
Request for Release of Personal Health Information | Request for Release of Personal Health Information under the Personal Health Information Protection Act, 2004 | Central, Central East, Central West, Champlain, Erie St. Clair, Global, Hamilton Niagara Haldimand Brant, Mississauga Halton, North East, North Simcoe Muskoka, North West, South East, South West, Toronto Central, Waterloo Wellington | September 19, 2024 | Forms | 2 MB | central central-east central-west champlain erie-st-clair global hamilton-niagara-haldimand-brant mississauga-halton north-east north-simcoe-muskoka north-west south-east south-west toronto-central waterloo-wellington | forms | |||
Short-Stay Respite Counselling Checklist for Community Patients | 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. | Champlain | July 8, 2024 | Forms | 266 KB | champlain | forms | |||
Soins de relève de courte durée Liste de choix de foyers de soins de longue durée | Veuillez choisir jusqu’à cinq foyers de soins de longue durée (FSLD) pour des soins de relève de courte durée, y compris des choix à l’extérieur de la région de Champlain, et les classer par ordre de préférence. Le nom de l’auteur de la demande sera ajouté aux listes d’attente des foyers choisis s’il elle est admissible et si les FSLD en question sont en mesure de fournir les soins requis. Santé à domicile Ontario confirmera les disponibilités des dates demandées. | Champlain | July 8, 2024 | Forms | 504 KB | champlain | forms | |||
Symptom Response Kit for End-of-Life Order Form | Symptom Response Kit for End-of-Life Order Form – Timing and placement of the Symptom Response Kit (SRK) requires careful consideration (i.e. prognosis is less than six months; patient expected to deteriorate quickly) with goal of avoiding emergency room visit or hospital admission. Medications in the SRK will expire; therefore, will need to be reviewed and reordered by the physician/Nurse Practitioner (NP) if it remains appropriate. Consider reviewing goals of care and expected home death protocols. | Champlain | July 8, 2024 | Forms | 365 KB | champlain | forms | |||
TeleHomeCare Remote Monitoring Program Referral Form | Please fax to: 613.745.8243 or 1.855.450.8569 | Champlain | October 7, 2024 | Forms | 263 KB | champlain | forms | |||
Télésoins à domicile : Programme de surveillance à distance | Formulaire de demande de services | Champlain | October 7, 2024 | Forms | 125 KB | champlain | forms |