Champlain

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 Office Locations

  • Ottawa (Corporate Office and Mailing Address)
    4200 Labelle St,
    Suite 100
    Ottawa, ON, K1J 1J8
    Toll-free:  1-866-902-5446
  • Bell’s Corners
    301 Moodie Dr.
    Suite 105
    Ottawa, ON, K2H 9C4
  • Cornwall
    709 Cotton Mill St.
    Cornwall, ON, K6H 7K7
  • Hawkesbury
    119 Main St. East
    Suite 101
    Hawkesbury, ON, K6A 1A1
  • Pembroke
    1100 Pembroke St. East
    Pembroke, ON, K8A 6Y7
  • Renfrew
    850 O’Brien Rd.
    Unit 8
    Renfrew, ON, K7V 3Z4
  • 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: champlainquality@hccontario.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 HCCSSmedia@hccontario.ca.

For non-media-related enquiries about Home and Community Care Support Services and to serve you best, please visit the Contact Us page to access additional contact information.

Forms

TitleSummaryRegionLast ModifiedCategoryFile TypeFile SizeLinkhf:doc_tagshf:doc_categorieshf:file_type
Application for Determination of Eligibility for LTC – English

Application for Determination of Eligibility for Long-Term Care – English

January 9, 2023pdf250 KBchamplainformspdf
Authorization for Release of Personal Health Information Form

Authorization for Release of Personal Health Information Form

September 19, 2022pdf522 KBchamplainformspdf
Authorization to Collect, Use, Disclose PHI Form – Bilingual

Authorization to Collect, Use, Disclose PHI Form – Bilingual

September 22, 2022pdf450 KBchamplainformspdf
Community IV Therapy Venous Access Algorithm

Community IV Therapy Venous Access Algorithm

September 19, 2022pdf118 KBchamplainformspdf
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

September 21, 2022pdf33 KBchamplainformspdf
Email Consent and Use Form – English

September 22, 2022pdf362 KBchamplainformspdf
Email Consent and Use Form – French

Email Consent and Use Form – French

September 22, 2022pdf307 KBchamplainformspdf
Family Managed Home Care Application Form – English

Family Managed Home Care Application Form – English

September 22, 2022pdf356 KBchamplainformspdf
Family Managed Home Care Application Form – French

Family Managed Home Care Application Form – French

September 22, 2022pdf338 KBchamplainformspdf
First Dose Parenteral Administration Form

First Dose Parenteral Administration Form

September 19, 2022pdf554 KBchamplainformspdf
Infusion Therapy – IV Remdesivir Referral Form

Champlain, Infusion Therapy – IV Remdesivir Referral Form

January 2, 2024pdf147 KBchamplainformspdf
Infusion Therapy Venous Access Referral Form

Infusion Therapy Venous Access Referral Form

September 19, 2022pdf382 KBchamplainformspdf
Integrated Bruyere Outpatient and Community Stroke Rehabilitation Referral Form

Integrated Bruyere Outpatient and Community Stroke Rehabilitation Referral Form

September 13, 2023pdf237 KBchamplainformspdf
Liste de choix de foyers de soins de longue durée

Champlain, Liste de choix de foyers de soins de longue durée

December 20, 2023pdf374 KBchamplainformspdf
Liste de choix de foyers de soins de longue durée

Champlain – Court séjour provisoire, Liste de choix de foyers de soins de longue durée

December 20, 2023pdf200 KBchamplainformspdf
Long-Term Care Home Crisis Choice List – Bilingual

Long-Term Care Home Crisis Choice List – Bilingual

June 20, 2023pdf400 KBchamplainformspdf
Long-Term Care Home Choice List

Champlain Long-Term Care Home Choice List – English

December 21, 2023pdf205 KBchamplainformspdf
Long-Term Care Home Short Stay Interim Choice List – English

Long-Term Care Home Short Stay Interim Choice List – English

December 20, 2023pdf75 KBchamplainformspdf
Long-Term Care Home Short-Stay Respite Choice List – English

Long-Term Care Home Short Stay Respite Choice List – English

December 20, 2023pdf140 KBchamplainformspdf
LTC Counselling Checklist – English

Long-term care counselling checklist for community patients.

October 11, 2023pdf161 KBchamplainformspdf
LTC Counselling Checklist – French

Patients dans la communauté – Liste de vérification des conseils pour admission en soins de longue durée

October 11, 2023pdf165 KBchamplainformspdf
LTC Counselling Checklist for Hospital Patients – English

Long-term care counselling checklist for hospital patients.

October 11, 2023pdf844 KBchamplainformspdf
LTC Counselling Checklist for Hospital Patients – French

Liste de vérification pour les patients hospitalisés – Renseignements sur les soins de longue durée

October 11, 2023pdf814 KBchamplainformspdf
Medical Referral Form

Medical Referral Form

September 19, 2022pdf389 KBchamplainformspdf
Medical Referral Infusions Pain and Symptom Management

Medical Referral Infusions Pain and Symptom Management

September 19, 2022pdf1 MBchamplainformspdf
Negative Pressure Wound Therapy Prescription Form

Negative Pressure Wound Therapy Prescription Form

September 19, 2022pdf525 KBchamplainformspdf
Referral Form for Home and Community Care Services

Champlain referral form for home and community care services

February 24, 2023pdf442 KBchamplainformspdf
Regional Palliative Consultation Team Referral Form

Regional Palliative Consultation Team Referral Form

September 19, 2022pdf233 KBchamplainformspdf
Short-Stay Respite Counselling Checklist

Short-Stay Respite Program in Long-Term Care Homes, Counselling Checklist for Patients in the Community

December 15, 2023pdf336 KBchamplainformspdf
Soins de relève de courte durée

Soins de relève de courte durée
Champlain – Soins de relève de courte durée Liste de choix de foyers de soins de longue durée

December 20, 2023pdf143 KBchamplainformspdf
Soins de relève de courte liste de vérification vérification des conseils

Programme de soins de relève de courte durée dans des foyers de soins de longue durée, Liste de vérification des conseils pour les patients dans la communauté

December 15, 2023pdf212 KBchamplainformspdf
Symptom Response Kit for End-of-Life Order Form – Champlain

Symptom Response Kit for End-of-Life Order Form – Champlain

January 23, 2023pdf333 KBchamplainformspdf
TeleHomeCare Remote Monitoring Program Referral Form

February 1, 2023pdf238 KBchamplainformspdf
Telehomecare Remote Monitoring Program Referral Form-FR

February 1, 2023pdf241 KBchamplainformspdf