Ontario's Ministry of Health funds certain allergen extracts for people eligible for the Ontario Drug Benefit program, and this form must be completed for the extract to be funded. The prescriber authorizes one prescription, describing the extract's contents and concentration, and forwards the form to the allergen extract supplier or pharmacy. The dispensary then completes its section and submits the claim.
The prescriber, a physician registered with the CPSO or a nurse practitioner registered with the CNO, completes and signs Section A; the dispensary completes Section B with the claim details.
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The prescriber completes Section A: prescriber name and college registration number with the CPSO or CNO code, patient name, date of birth and ODB eligibility or health number, the contents and concentration of the extract, and a signature. The dispensary completes Section B when billing.
Up to two years from the date the prescriber signs it, covering the one prescription for the allergen extract described and any refills authorized under that prescription. A new form is required for a different extract or when another prescriber writes the prescription.
The prescriber forwards it to the allergen extract supplier or pharmacy. The dispensary completes Section B, certifies that the costs reflect the actual acquisition cost with only the eligible mark-up, and submits the claim to the Ministry of Health's Claims Services Branch.