Région de Nord-Est

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

North East – Referral form for administering COVID-19 antivirals in North East community nursing clinics.

Orders with missing information will be sent back to the authorizer for completion and delay order processing. HCCSS Manager approval is required for duplication of equipment. Without approval, the order will not be processed. The default rental period is 30 days.

*Note: Vendor will contact client when supplies are ready for pickup at depot or to coordinate private-pay patient home delivery requests

Fax: 1-855-697-7358 / Right Fax: 3829
*Hospital: Use hospital Ontario Health atHome fax number

Fax: 1-855-697-7358 / Right Fax: 3829

*Hospital: Use hospital Ontario Health atHome fax number

Fax: 1-855-697-7358 / Right Fax: 3829

*Hospital: Use hospital Ontario Health atHome fax number

Fax: 1-855-697-7358 / Right Fax: 3829

*Hospital: Use hospital Ontario Health atHome fax number

Fax: 1-855-697-7358 / Right Fax: 3829

*Hospital: Use hospital Ontario Health atHome fax number

Fax to OH atHome Office: Regional Equipment & Supplies 1-855-697-7358 or Right Fax: 3829

Mental Health and Addictions Nursing Program Referral Form

Medical Equipment and Supply Fax Number: 1-855-697-7358 Right Fax: 3829
*Hospital: Use hospital Ontario Health atHome fax number

*Not a pathway or wound type – use guidelines when NPWT is initiated in conjunction with pathway that is appropriate for wound type.

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.

For equipment to be delivered same day: the requisition must be received by the Regional Equipment and Supply TA no later than 3:30 p.m. as our Vendor must receive it before 4 pm to ensure same day delivery.
It is important for the therapists to know that the vendor has until 9 pm to deliver equipment ordered for delivery that day. There is no guaranteed delivery time.

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Referral for Central Venous Access Device (CVAD) Through Regional Cancer Program form

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Referral for Ontario Health atHome Services in North East

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

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