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Forms and Applications

• Long Term Care and Community Support Program
• Medical Care Plan (MCP)
• Prescription Drug Program (NLPDP)
• Mental Health Care and Treatment Act
• Healthcare Providers
• Medical Assistance in Dying

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)

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Medical Care Plan (MCP)

• Application for Newfoundland and Labrador Health Care Coverage (46 KB)
  • Demande de couverture pour services des soins de santé à Terre-Neuve-et-Labrador (246 KB)
• Card Replacement/Information Update (34 KB)
  • Remplacement de la carte / mise à jour des renseignements (164 KB)
• Newborn / Adopted Child Registration (33 KB)
  • Inscription des nouveau-nés et des enfants adoptés (143 KB)
• Application for Out-of-Province Coverage Certificate (28 KB)
  • Demande de certificat de couverture hors de la province (30 KB)
• Out of Province Claim (37 KB)
• Request for Release of Beneficiary Medical Care Plan (MCP) Number (28 KB)
• Request for Medical Claims History Information (85 KB)
• Dental Application Form (103 KB)
• Adult Dental Reimbursement Form (33 KB)
• Assignment of Payment Agreement (67 KB)
• Electronic Billing Application (761 KB)
• Provider Registration Form (330 KB)
  • Provider Registration Form Completion Guide (223 KB)
• Medical Care Plan (MCP) Locum Documentation / Declaration (158 KB)
• Provisionally Licensed Physicians Policy / Approval to Bill Fee for Service (167 KB)
• Salaried Physician Request / Approval to Bill Temporary Fee for Service (683 KB)

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Prescription Drug Program (NLPDP)

Applications:

• 65 Plus Plan for Landed Immigrants (431 KB)
• Dental Application Form (103 KB)
• NLPDP Application Form (226 KB)

Consent:

• NLPDP Consent Form (60 KB)

Programme de médicaments sur ordonnance de Terre‑Neuve‑et‑Labrador (NLPDP)

Demandes :

• Régime 65 Plus Plan pour les immigrants reçus (104 ko)
• Formulaire de demande pour soins dentaires (103 ko)
• Formulaire de demande au titre du NLPDP (226 ko)

Consentement :

• Formulaire de consentement du NLPDP (60 ko)

Order Forms:

• Tamper Resistant Prescription Drug Pad Plan
  • Order Form for Prescribers (166 KB)
  • Order Form for Facilities (166 KB)

Special Authorization Request Forms:

• Brilinta (322 KB)
• DM Type 2 High Cardiovascular Risk (86 KB)
• Donepezil, Galantamine and Rivastigmine (230 KB)
• Chronic Obstructive Pulmonary Disease (181 KB)
• Chronic Plague Psoriasis Medication (71 KB)
• Pirfenidone and Nintedanib (291 KB)
• Hepatitis C Treatments (118 KB)
• Inflammatory Bowel Diseases (205 KB)
• Jetrea (175 KB)
• Levemir (76 KB)
• Retinal Diseases (293 KB)
• Methadone Daily Dispensing (56 KB)
• Oral Diabetes Medications (372 KB)
• Truvada PrEP (113 KB)
• Methadone Take Home Doses (132 KB)
• Rheumatoid Arthritis Medications- Initiation of Coverage (105 KB)
• Rheumatoid Arthritis Medications- Continuation of Coverage (69 KB)
• Sevelamer (267 KB)
• Standard Special Authorization Form (69 KB)
• Tamiflu for Long Term Care Residents (111 KB)
• Test Strips for Blood Glucose Monitoring (169 KB)
• Thromboembolism Prevention Following Surgery (294 KB)
• Xarelto/Pradaxa/Eliquis/Lixiana- Atrial Fibrillation (213 KB)

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Mental Health Care and Treatment Act

• Certificate of Involuntary Admission (323 KB)
• Certification Renewal (670 KB)
• Community Treatment Order (325 KB)
• Authorized Patient Pass (822 KB)
• Apprehension Conveyance Re Unauthorized Leave (717 KB)
• Notification CTO No Longer in Effect (200 KB)
• Order for the Apprehension Conveyance and Examination (219 KB)
• Authorization to Transfer to Another Psychiatric Unit (197 KB)
• Authorization to Transfer to Another Jurisdiction (197 KB)
• Authorization to Transfer into the Province (255 KB)
• Involuntary Certification Checklist (692 KB)
• Application for Review by the Mental Health Care and Treatment Review Board (222 KB)
• Community Treatment Order Checklist (612 KB)

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Healthcare Providers

• Medical Care Plan (MCP) Assignment of Payment Agreement (73 KB)
• Medical Care Plan (MCP) Electronic Billing Application (761 KB)
• Medical Care Plan (MCP) Provider Registration Form (83 KB)
• Medical Care Plan (MCP) Provider Registration Form Completion Guide (93 KB)
• Medical Care Plan (MCP) Locum Documentation / Declaration (159 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)

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Medical Assistance in Dying

• Medical Assistance in Dying Patient Request Record Eastern Health (485 KB)
• Medical Assistance in Dying Patient Request Record Central Health (486 KB)
• Medical Assistance in Dying Patient Request Record Western Health (486 KB)
• Medical Assistance in Dying Patient Request Record Labrador-Grenfell Health (488 KB)

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