Forms

Nurse Practitioner Service Encounter Reporting and Tracking (SERT)

Forms are listed alphabetically in Portable Document Format (PDF). To view and print the forms, you need to have Adobe Acrobat? Reader installed on your computer. You can download this free software from the Adobe Web site.

Click on the form title to open the form. You can fill-in the form on your screen and print it, or use the disk icon on the Reader toolbar to save a blank copy of the form to your computer. Filled-in forms cannot be saved.

4752-84 Undertaking by Interdisciplinary Health Providers (IHP) for Participation in Machine Readable Input (MRI) Fill & Print
4751-84 Interdisciplinary Health Provider (IHP) Nurse Practitioner (NP) Authorization for Participation in the NP Service Encounter Reporting and Tracking (SERT) Initiative Fill & Print
4750-84 Application for IHP GONet Electronic Data Transfer (EDT) Service Fill & Print
4749-84 IHP Electronic Data Transfer (EDT) Undertaking and Acknowledgement Fill & Print
4747-84 Application for IHP Claims Submission and Remittance Advice in Machine Readable Input (MRI) Fill & Print
4746-84 Interdisciplinary Health Provider (IHP) Health Number Release Fill & Print
4744-84 Interdisciplinary Health Provider (IHP) Application for Direct Bank Payment Fill & Print
4722-84 Application for IHP Group Registration Fill & Print
4721-84 IHP Electronic Data Transfer (EDT) Undertaking and Acknowledgement for Nurse Practitioners (NP) Fill & Print

For More Information

Call ServiceOntario, Infoline at:
1-866-532-3161 (Toll-free)
In Toronto, (416) 314-5518
TTY 1-800-387-5559.
In Toronto, TTY 416-327-4282
Hours of operation : Monday to Friday, 8:30am - 5:00pm