Patients diagnosed with an eligible metabolic disorder can receive funded products through Ontario's Inherited Metabolic Diseases (IMD) Program, and this three-page form is the application and consent to join it. A treating physician at one of six designated hospitals completes the clinical sections, and the patient or substitute decision-maker signs the declaration. The ministry then records its approval of the registration.
A physician, usually the treating physician named in Section 2, completes the application and must sign Section 5 with a CPSO number; the patient or their substitute decision-maker signs the declaration and consent on the last page.
Download the current version from the source each time; forms change without notice.
Application and Consent for the Inherited Metabolic Diseases (IMD) Program
Formulaire de demande et de consentement Programme de dépistage de maladies métaboliques héréditaires
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Section 5 requires a physician signature with CPSO number. If the physician completing the application is not the treating physician named in Section 2, they add their own address and contact details. The patient, or a substitute decision-maker with authority, signs the declaration and consent on page three.
The patient must be treated by a physician at the Children's Hospital of Eastern Ontario, the Hospital for Sick Children, Kingston Health Sciences Centre, London Health Sciences Centre, McMaster Children's Hospital or the University Health Network, according to the eligibility rules printed on form 4551-87E.
The ministry recommends the SADIE portal for faster approval. Alternatively, fax or mail the completed form to the Delivery and Eligibility Review Branch of the Ministry of Health. Because it is an XFA form, open it in Adobe Acrobat or Reader rather than a browser to fill it in.