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Ontario Form 0225-47: Erythropoietin Funding for ESRD

Ontario's Special Drugs Program provides recombinant human erythropoietin to patients with end-stage renal disease, and this one-page bilingual form registers a patient for that funding. The treating hospital's renal program records dialysis type, latest hemoglobin, the indication and the initial weekly dose. Enrolment data are used to summarize erythropoietin use for all treated patients each quarter.

Who completes it

The treating physician and hospital renal program complete the whole form, including the hospital name, patient identifiers, dialysis details, indication, previous treatment and initial dosage, with the physician's name.

Submitting and payment

How to submit it
The treating hospital submits it to the Ministry of Health's Special Drugs Program; the white copy goes to the ministry's Drug Programs Policy and Strategy Branch, the canary copy to the dialysis centre and the pink copy to the hospital pharmacy and therapeutics committee.

Good to know

  • Indications listed include being on a transplant list, transfusion reactions, cross-match difficulties, severe symptomatic anemia, iron overload, or hemoglobin below 55 g/L, each in a patient who would otherwise need transfusion.
  • Known risk factors for non-response should be excluded before treatment, including infection or inflammation, aluminum toxicity, occult blood loss, iron, folic acid or B12 deficiency, hemolysis and hematologic disease.
  • Dosing follows the approved product monograph, and the form reminds users that care should be taken to avoid wastage of the product.
  • The current version is 0225-47 (2022/08), a bilingual English and French form without fillable fields.

Get the official form

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

Recombinant Human Erythropoietin Funding Enrollment for E.S.R.D. Patients

Inscription à l'aide financière pour malades souffrant d'insuffisance rénale terminale

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it 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

Who submits Ontario's ESRD erythropoietin enrolment form?

The treating hospital. The form starts with the hospital name and is completed by the renal program and treating physician, then registered with the Ministry of Health's Special Drugs Program. Separate copies go to the ministry, the dialysis centre and the hospital's pharmacy and therapeutics committee.

What indications qualify on form 0225-47?

The form lists being on a transplant list, a previous transfusion reaction (with the number of transfusions in the last year), cross-match difficulties, severe symptomatic anemia, iron overload with serum ferritin, and severe anemia with hemoglobin under 55 g/L, each in a patient who would otherwise require transfusion.

Is the Ontario erythropoietin enrolment form available in French?

Yes, it is a single bilingual form. The French title, 'Inscription à l'aide financière pour malades souffrant d'insuffisance rénale terminale', is printed alongside the English on the same page, and the Central Forms Repository offers the form as a PDF or an HTML version.