• Home
  • Forms and Applications

Forms and Applications

• Long Term Care and Community Support Program
• Medical Care Plan (MCP)
• Prescription Drug Program (NLPDP)
• Go Healthy
• Mental Health Care and Treatment Act
• Blood Coordinating Program
• Healthcare Providers
• Home Heating Rebate Application (30 KB)

Note: all links below are PDFs and will open in a new window.

Long Term Care and Community Support Program

• Long Term Care and Community Support Program Adult Needs Assessment (152 KB)
• Long Term Care and Community Support Program Adult Needs Reassessment (60 KB)
• Reference Manual Long Term Care and Community Support Program Adult Needs Assessment (522 KB)

^ Top of Page

Medical Care Plan (MCP)

• Application for Newfoundland and Labrador Health Care Coverage (423 KB)
  • français (149 KB)
• Card Replacement (122 KB)
  • français (88 KB)
• Change of Address (122 KB)
  • français (88 KB)
• Change of Name (122 KB)
  • français (88 KB)
• Newborn / Adopted Child Registration (65 KB)
  • français (113 KB)
• Application for Out-of-Province Coverage Certificate (65 KB)
  • français (118 KB)
• Out of Province Claim (99 KB)
  • français (143 KB)
• Request for Release of Beneficiary Medical Care Plan (MCP) Number (80 KB)
• Request for Release of Beneficiary Claim Information (66 KB)
• Termination of Coverage (122 KB)
  • français (88 KB)
• Dental Application Form (103 KB)
• Assignment of Payment Agreement (73 KB)
• Electronic Billing Application (41 KB)
  • Guidelines For Providers Who Submit From More Than One Location (9 KB)
• Provider Registration Form (86 KB)
  • Provider Registration Form Completion Guide (37 KB)
• Medical Care Plan (MCP) Locum Documentation / Declaration (73 KB)
• Request for Release of Beneficiary Medical Care Plan (MCP) Number (80 KB)
• Provisionally Licensed Physicians Policy / Approval to Bill Fee for Service (73 KB)
• Salaried Physician Request / Approval to Bill Temporary Fee for Service (89 KB)

^ Top of Page

Prescription Drug Program (NLPDP)

• NLPDP Consent Form (60 KB)
• NLPDP application form (110 KB)
• Fax Sheet for Special Authorization Priority Review (77 KB)
• Methadone Carry Dose (68 KB)
• Request for Continuation of Coverage of Cholinesterase Inhibitors Special Authorization Form (62 KB)
• Request for Initial Coverage of Cholinesterase Inhibitors Special Authorization Form (96 KB)
• Standard Special Authorization Request Form (69 KB)
• Clopidogrel Special Authorization Request Form (73 KB)
• Sevelamer Special Authorization Form (73 KB)
• Crohn's Meds Request Form (72 KB)
• RA Meds Initiation of Coverage Request (105 KB)
• RA Meds Continuation of Coverage Request (69 KB)
• Methadone Special Authorization Request Form (70 KB)
• Chronic Plague Psoriasis Meds Coverage Request (71 KB)
• Request for Rivaroxaban(Xarelto) (61 KB)
• Dental Application Form (103 KB)
• 65 Plus Plan for Landed Immigrants (104 KB)
• Tamper Resistant Prescription Drug Pad Plan - Order Form (135 KB)
  • For Prescribers (90 KB)
  • For Facilities (89 KB)

^ Top of Page

Go Healthy

• Health Promotion Strategies and Determinants of Health (66 KB)
• Contact Information within Regional Health Authorities (47 KB)
• 2008-2009 Funded Projects (107 KB)
• 2007-2008 Funded Projects (89 KB)
• 2006-2007 Funded Projects (67 KB)
• 2005-2006 Funded Projects (82 KB)

^ Top of Page

Mental Health Care and Treatment Act

• Certificate of Involuntary Admission (54 KB)
• Certification Renewal (56 KB)
• Community Treatment Order (68 KB)
• Community Treatment Plan (60 KB)
• Authorized Patient Pass (48 KB)
• Order for the Apprehension & Conveyance Re Unauthorized Leave (56 KB)
• Notification CTO No Longer in Effect (56 KB)
• Order for the Apprehension Conveyance and Examination (56 KB)
• Authorization to Transfer to Another Psychiatric Unit (48 KB)
• Authorization to Transfer to Another Jurisdiction (48 KB)
• Authorization to Transfer into the Province (48 KB)
• Community Addictions Prevention and Mental Health Promotion Fund Application Form (104 KB)
• Involuntary Certification Checklist (336 KB)
• Application/Withdrawal of Application for Review by the Mental Health Care and Treatment Review Board (92 KB)

^ Top of Page

Blood Coordinating Program

• Inter Hospital Transfer form (35 KB)
• Inter Hospital Transfer form Sample completed (44 KB)
• Interhospital Transfer Notification form (23 KB)
• Courier Log Sheet (18 KB)
• Shipper Label Sample (20 KB)
• Pre-Conditioning of Blood Product Shipping Container (23 KB)
• RSV Request Form (57 KB)
• Synagis Product Disposition Log (45 KB)
• Octaplex Request Form (53 KB)

^ Top of Page

Healthcare Providers

• Medical Care Plan (MCP) Assignment of Payment Agreement (73 KB)
• Medical Care Plan (MCP) Electronic Billing Application (41 KB)
• Medical Care Plan (MCP) Guidelines For Providers Who Submit From More Than One Location (9 KB)
• Medical Care Plan (MCP) Provider Registration Form (83 KB)
• Medical Care Plan (MCP) Provider Registration Form Completion Guide (37 KB)
• Medical Care Plan (MCP) Locum Documentation / Declaration (73 KB)
• Medical Care Plan (MCP) Request for Release of Beneficiary Medical Care Plan (MCP) Number (80 KB)
• Medical Care Plan (MCP) Provisionally Licensed Physicians Policy / Approval to Bill Fee for Service (73 KB)
• Medical Care Plan (MCP) Salaried Physician Request / Approval to Bill Temporary Fee for Service (89 KB)

^ Top of Page

Adobe® Acrobat® Reader software can be used for viewing PDF documents. Download Acrobat® Reader for free .