North Simcoe Muskoka 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.

TO ALL PALLIATIVE CARE PROVIDERS
(For the purpose of this form, an individual refers to a patient or client)
Your submission of this form will be taken to explicitly mean that you have gained appropriate permission for release of the information contained to the agencies and services to whom you are submitting this. Please also include your Organization’s Release of Information Form, if applicable.

Common Palliative Referral Guidelines

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

Important Note: Please follow these instructions (opens in a new tab) to access the form.
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.

MAID Referral

North Simcoe Muskoka Medical Referral Form Adult

Medical Referral Form Child

Medical Referral Guidelines PCP Children – English

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.

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

Please fax back to ontario health athome 705‐792‐6270

Patients enrolled in the COVID-19 Remote Monitoring Program use an app on their smartphone to report their symptoms to their nurse.

Telehomecare Referral Form