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NHTG Specialty-Service Provider Form (ON00857)

Patients applying online for Ontario's Northern Health Travel Grant need this one-page form from the specialist or ministry-funded facility that provided their OHIP-insured service. It replaces Section 6 of the paper application: the provider confirms the service and declares the medically necessary lodging nights, which determine the accommodation allowance. The patient uploads it to the NHTG Online Form.

Who completes it

The specialty-service provider, a medical specialist or ministry-funded facility, completes and signs Section 2 with service details, lodging nights, the physician fee code and provider information. The patient completes the rest of the online application.

Submitting and payment

How to submit it
The patient attaches the signed form to the NHTG Online Form (ON00817) and submits it online. For mailed paper applications, the provider completes Section 6 of form 0327-88E instead.

Good to know

  • Use this form only for online applications; a patient who mails a paper application needs Section 6 of form 0327-88E completed instead.
  • It is an XFA e-form that opens and fills correctly only in Adobe Acrobat or Reader, not in browsers or most PDF viewers.
  • The provider declares the medically necessary lodging nights, and for service dates on or after December 1, 2024, those nights set the accommodation allowance.
  • The patient must still meet NHTG rules, including OHIP-insured specialist care at least 100 km away and an application received within 12 months of the service.

Get the official form

Download the current version from the source each time; forms change without notice.

Specialty-Service Provider Form for Northern Health Travel Grant

Formulaire du fournisseur de services spécialisés pour la subvention aux résidents du Nord pour frais de transport à des fins médicales

Official pagePDFVersion française

Fill it with Vero

Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.

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Frequently asked questions

When does a specialist need form ON00857 instead of Section 6?

When the patient applies online. The ministry says this form is used only for patients submitting NHTG applications through the online form, where it is uploaded as an attachment. For mailed applications, the specialist completes Section 6 of the paper application, form 0327-88E.

Is the specialty-service provider form available in French?

Yes. The ministry's forms repository posts a French edition, ON00857F, titled Formulaire du fournisseur de services spécialisés pour la subvention aux résidents du Nord pour frais de transport à des fins médicales, alongside the English ON00857E.

Why won't form ON00857 open in a browser?

It is an XFA-based e-form that opens and fills correctly only in Adobe Acrobat or Adobe Reader; browsers and most PDF viewers show a message asking for Adobe Reader or cannot render the fields. Download it and open it in Adobe Reader before completing it.