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Forms and Applications : Health Care Provider Access to Prescription Drug History

Consent Withdrawal/Reinstatement Forms for Ontario Drug Benefit program Recipients

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.

To print, use the printer icon on the Reader toolbar. For form sizes larger than 8.5 x 11 inches, check the Fit to Page box in the print menu window. See the Forms and Applications main menu page for detailed instructions.

4385-87 Full Withdrawal of Consent Form VIEW & PRINT
4386-87 Partial Withdrawal of Consent Form VIEW & PRINT
4387-87 Consent Reinstatement VIEW & PRINT

For more information
Call the ministry INFOline at 1-866-752-6405
(Toll-free in Ontario only)
TTY 1-800-387-5559
Hours of operation : 8:30am - 5:00pm
  
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