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Ontario TB-UP Provider Claim Form (3977-84E)

Ontario's Tuberculosis Diagnostic and Treatment Services for Uninsured Persons program (TB-UP) uses this claim to pay physicians and other providers for diagnosing or treating active or latent TB, or assessing suspected TB, in people without health insurance. The patient must first be registered for TB-UP at a public health unit, which supplies the registration number. Payment follows OHIP Schedule of Benefits fee codes.

Who completes it

The public health unit completes Part A, or helps complete it, with the patient's TB-UP registration number, eligibility expiry date and disease under investigation. The service provider completes Part B, listing each service by program ID and service code with the fee and date, and signs it.

Submitting and payment

How to submit it
Enter TB-UP as the Program Identification Code, remove the instruction page, and mail the claim to the Ministry of Health, since there is no electronic submission option. Claims must be submitted within six months of the date of service.
Who pays
The Ministry of Health pays using the OHIP Schedule of Benefits fee codes and amounts in effect on the service date, prefaced by the TB-UP program code, and that payment is payment in full.

Good to know

  • TB-UP services aren't OHIP insured services and don't count toward OHIP payment thresholds, but the Schedule of Benefits General Preamble still applies with necessary modifications.
  • You can't bill the patient or anyone else for a service paid under TB-UP, and you can claim only if no insurer or other public program would pay for it.
  • If the eligibility expiry date has passed, the service was provided outside Ontario, or you need more claim forms, contact the public health unit named on the form first.
  • The ministry aims to pay within 8 weeks of receipt. Incomplete claims, or claims for services not approved under TB-UP, are returned with a letter explaining why.

Get the official form

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

Health Care Provider Claim - Diagnostic and Treatment Services for Uninsured Persons

Demande de règlement d'un fournisseur de soins de santé - Programme de diagnostic et de traitement pour les personnes non assurée

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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.

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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

Which services can be claimed under Ontario's TB-UP program?

Only services provided to diagnose or treat active or latent tuberculosis, or to assess suspected TB infection, for clients without health insurance who are registered for TB-UP at a public health unit. In Part B, the provider confirms the listed services were solely for the disease named under the program identification.

How are TB-UP claims paid?

The ministry pays based on OHIP Schedule of Benefits fee codes and amounts, keyed with the TB-UP program code, and aims to pay within 8 weeks of receipt. Keep a copy of the claim for cheque identification and reconciliation. Payment questions go to the Ministry of Health; program and policy questions go to the local public health unit.

Is there a deadline for TB-UP claims?

Yes. All claims, including resubmitted ones, must be submitted within six months of the date of service, regardless of payment inquiries. Later claims are refused unless the TB-UP program manager is satisfied there were extenuating circumstances. There is no electronic option, so allow time for mailing.