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 0691-84E: Approval for Proposed Surgery
Surgeons use this request to ask the Ministry of Health to approve payment before performing a procedure that needs prior approval under OHIP. It lists the proposed fee codes, diagnosis, procedure and medical indication for surgery. The ministry approves it as submitted, approves it as amended or rules it not an eligible benefit, and an approval stays valid for one year.
Who completes it
The surgeon completes the patient identification and surgery details: hospital name and address, surgery date if known, proposed fee codes, diagnosis and proposed procedure, medical indication, and their name, Ministry of Health billing number, address and signature. The ministry completes the assessment section.
Submitting and payment
- How to submit it
- Forward a copy to the surgeon's Ministry of Health claims processing office; if the request is approved, return a copy of the form with the claim.
- Who pays
- Approval allows OHIP payment for the proposed procedure only if the patient's Ontario health coverage is in effect on the date of service; the form lists no fee for completing the request.
Good to know
- The ministry's authorization is valid for one year after the date of approval, and approval as submitted or as amended applies only while Ontario health coverage is in effect.
- The ministry may approve the request as submitted, approve it as amended with comments, or mark it as not an eligible benefit.
- The form is marked confidential when completed and is posted in English (0691-84E) and French (0691-84F) as an XFA fillable PDF for Adobe Acrobat or Reader.
Get the official form
Download the current version from the source each time; forms change without notice.
Request for Approval of Payment for Proposed Surgery
Demande d'approbation de reglement de frais d'actes chirurgicaux proposees
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
How long is OHIP approval for a proposed surgery valid?
The form states that the authorization is valid for one year after the date of approval. Approval as submitted or as amended also depends on the patient's Ontario health coverage being in effect on the date of service, and a copy of the approved form goes back with the surgeon's claim.
Where is form 0691-84E sent?
The instructions to surgeons say to forward a copy of the form to their Ministry of Health claims processing office, then return a copy of the form with the claim if the request is approved. The ministry's assessment section records approval as submitted, approval as amended, or not an eligible benefit.