Get Odsp Mandatory Special Necessities Benefit Request Form

Mandatory Special Necessities MSN Benefit Request Physician / Health Care Professional please fax completed forms to 519. 482. 1632 or mail to address below. Name of individual requiring items/services Member ID Team Ontario Works OW may provide funding for transportation needed to obtain medical treatment. Costs for diabetic supplies surgical supplies and dressings are also covered. Verification of the medical necessity is required. While we appreciate your cooperation in completing this form we are unable to accept responsibility for any fee attached to providing this documentation. Medical Transportation This section may be completed by Ontario licensed physicians Registered Nurses in the Extended Class and psychologists for addiction related travel only. Mandatory Special Necessities MSN Benefit Request Physician / Health Care Professional please fax completed forms to 519. 482. 1632 or mail to address below. Name of individual requiring items/services Member ID Team Ontario Works OW may provide funding for transportation needed to obtain medical treatment. Costs for diabetic supplies surgical supplies and dressings are also covered* Verification of the medical necessity is required* While we appreciate your cooperation in completing this form we are unable to accept responsibility for any fee attached to providing this documentation* Medical Transportation This section may be completed by Ontario licensed physicians Registered Nurses in the Extended Class and psychologists for addiction related travel only. Physician/Facility Name of Visits per month Location Type of transportation required Taxi Town Country Support Services Required From Required Until mm/yy Private Vehicle Diabetic Supplies Glucometer Required Lancets Number required per day Other please specify number Syringe Needle Tips Yes No Surgical Supplies provide for the costs of surgical supplies and dressings not otherwise provided for. For OW purposes surgical supplies and dressings are considered to be those supplies prescribed by a licensed Ontario physician and required as a direct result of a surgical radiological or medical procedure or disease. Item Period Required daily/weekly/etc Required Until / per Form completed by Name of Physician or Health Professional Phone Date Print Form County of Huron Social Services - Ontario Works 77722D London Road RR 5 Clinton ON N0M 1L0 Telephone 519. Mandatory Special Necessities MSN Benefit Request Physician / Health Care Professional please fax completed forms to 519. 482. 1632 or mail to address below. Name of individual requiring items/services Member ID Team Ontario Works OW may provide funding for transportation needed to obtain medical treatment. 482. 1632 or mail to address below. Name of individual requiring items/services Member ID Team Ontario Works OW may provide funding for transportation needed to obtain medical treatment. Costs for diabetic supplies surgical supplies and dressings are also covered* Verification of the medical necessity is required* While we appreciate your cooperation in completing this form we are unable to accept responsibility for any fee attached to providing this documentation* Medical Transportation This section may be completed by Ontario licensed physicians Registered Nurses in the Extended Class and psychologists for addiction related travel only.