Referral of a patient to Ontario Health atHome for home and community care services.
- Completed by
- Referring physician, NP or other provider
- Issued by
- Ontario Health atHome
- Format
- Language
- English
OHIP Form 0000-80: Out of Province Physician Claim
This claim covers physician services an Ontario resident received elsewhere in Canada that were not billed through reciprocal billing. The patient completes Parts A and B, and the treating physician completes Part C with the diagnosis, fee codes and fees. The bilingual form then goes to OHIP from either the patient or the physician, with payment directed to one or the other.
Who completes it
The treating physician completes Part C: specialty, place of service, hospital admission and discharge dates, each procedure with its fee code, fee and date, diagnosis, any third-party involvement, the payee choice and signature. The patient or parent/guardian completes Part A (travel details and reason for absence) and signs the Part B declaration.
Submitting and payment
- How to submit it
- The completed claim is sent to OHIP by the patient or by the physician.
- Who pays
- In Part C the physician ticks either pay physician, accepting the patient's plan payment as payment in full, or pay patient, so the plan payment goes to the patient.
Good to know
- Part C flags claims involving workers' compensation, a pensionable disability, an automobile accident or another third party, and records anaesthetist, surgical assistant or psychiatrist time in hours and minutes.
- Inpatient claims mark each service date on a 31-day calendar grid and give the hospital name with admission and discharge dates.
- The posted edition dates from 2003 and is bilingual: English on page 1 and French (Réclamation hors province pour services médicaux) on page 2, with a language-of-correspondence choice.
- Part B is a declaration under the Canada Evidence Act that the patient is a beneficiary of their home province's medical care plan.
Get the official form
Download the current version from the source each time; forms change without notice.
Out of Province Claim for Physician Services
Réclamation hors province pour services médicaux
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.
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 fills in the Out of Province Claim for Physician Services?
The patient, or a parent or guardian, completes Part A with health card details, travel dates, the place of treatment and the reason for being away, then signs Part B. The treating physician completes and signs Part C with the services, fee codes, fees and diagnosis.
Can the physician be paid directly with this claim?
Yes. Part C has a pay physician option in which the physician accepts the patient's plan payment as payment in full; otherwise the physician selects pay patient. In the Part B declaration the patient also indicates whether payment should go directly to the physician or to the patient.