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 4347-84E: Request for Major Eye Examination
A physician or nurse practitioner uses this requisition to recommend an OHIP-insured major eye exam, once every 12 months, for a patient whose medical condition affects the eye but is not on the direct-access list. Since September 1, 2023, it applies only to exams provided by physicians, not optometrists. The requisition names the examining physician and stays valid for several fiscal years.
Who completes it
The physician or nurse practitioner completes Section 2 (why the patient needs a major eye exam every 12 months) and Section 3 (name, OHIP billing number, signature), plus the patient details in Section 1. Section 4 records the name of the physician who will provide the major eye exam.
Submitting and payment
- How to submit it
- The form gives no mailing or fax address: it works as a requisition naming the examining physician in Section 4, and it is valid until March 31, five fiscal years after the date of signature.
- Who pays
- The form states that a fee may be claimed for completing the request under OHIP fee code E077.
Good to know
- Patients with diabetes, glaucoma, corneal disease, cataract, retinal disease, optic pathway disease, amblyopia, visual field defects, strabismus or recurrent uveitis can book a physician major eye exam directly, without this form.
- Since September 1, 2023, the request no longer applies to services rendered by optometrists; it covers only major eye exams provided by a physician.
- A new requisition can be issued before the current one expires if the patient wants the exam from a provider other than the one named in Section 4.
- The current edition is 4347-84E (2025/09), an XFA fillable PDF that shows only a placeholder in browsers and needs Adobe Acrobat or Reader.
Get the official form
Download the current version from the source each time; forms change without notice.
Request for Major Eye Examination
Demande d'examen complet de la vue
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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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 can recommend a major eye exam with form 4347-84E?
A physician or nurse practitioner. They describe the medical condition affecting the eye that requires a major eye exam every 12 months, give their OHIP billing number and sign to verify the information. The exam itself must be provided by a physician, because the form no longer applies to optometrists.
Does a patient with diabetes need this form for an eye exam?
No. The form lists conditions whose patients can directly access a major eye exam from a physician without a requisition: type 1 or 2 diabetes, glaucoma, corneal disease, cataract, retinal disease, optic pathway disease, amblyopia, visual field defects, strabismus and recurrent uveitis.
How long is a major eye exam requisition valid?
Until March 31, five fiscal years after the date the physician or nurse practitioner signs it. Within that period the patient may have a major eye exam once every 12 months, and a new requisition can be provided early if the patient switches to a different examining provider.