Forms
Application for Consent to Transfer a Licence
The Licence Transfer Application must be submitted when requesting the Director of Integrated Community Health Services Centres’ (Director) approval regarding the transfer of a centre. This application must be signed by the current licensee and the proposed transferee.
No transfer of ownership of a licence can take place without the prior written approval of the Director.
Licence transfers will cancel any active relocation or expansion applications.
Download the Application for Consent to Transfer a Licence form
Amalgamation and share transfer
Please send a cover letter detailing the share transfer and complete relevant sections of the Transfer Application:
- Part 1 sections A & B
- Part 2 Section A (if Contact Person details have changed)
- Appendix A (as many times as needed)
Please note that the order in which your share transfer and/or amalgamation appear in your cover letter will be the order in which we process your requested changes. For example, if the share transfer must occur first, it should be described first in your letter.
Download the Application for Consent to Transfer a Licence form
ICHSC Physician Affiliation Authorization
When the Integrated Community Health Services Centres (ICHSC) Program receives a request to affiliate a physician to a centre, the program will confirm the physician's qualifications to provide the requested services prior to processing the affiliation. This may require the licensee and/or the physician to provide additional information for review (for example, a letter acknowledging their qualifications from the College of Physicians and Surgeons of Ontario (CPSO)). The licensee must ensure that the physician has been affiliated to the centre before they begin to provide licensed services.
Quality Advisor Acknowledgement
Licensees are required to appoint and maintain a quality assurance advisor to oversee the quality assurance program at the community surgical and diagnostic centre and provides quality-related advice to the Licensee. The ICHSC Program must be notified of a change in quality assurance advisor through the submission of the Quality Assurance Advisor form which must be signed by both the centre’s quality assurance advisor and the licensee.
Download the Quality Assurance Advisor form.
Relocation
The policy for relocations is included in the Fixed Site Relocation application and is found starting on page 7.
No relocation of a licence to a new location can take place without the prior written approval of the Director.
There are different criteria if the move is:
- less than 5 kilometers
- more than 5 kilometers but in the same catchment zone
- more than 5 kilometers and outside of the current catchment zone
Approval for a relocation is valid for 12 months from date of the Director’s decision. If a Licensee decides not to move forward with the approved relocation, they are required to advise the ICHSC program.
Download the Fixed Site Relocation application.
Expansion
The Application for the Expansion of Fixed Facilities form allows centres to request new services to be added to their existing licence.
The addition of a new service to an existing licence requires the prior written approval of the Director.
Only the current licensee (either a person or corporation) is eligible to submit an expansion application. An application to expand a licence will be cancelled if there is a pending application to transfer ownership of the centre.
A facility must be operating under the current licensee, providing licensed services in its current location for six months, before submitting an expansion application.
To receive a copy of this form please email the program area at ICHSC@ontario.ca.