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LTC Health Assessment Form 4768-69E (Ontario)

Ontario Health atHome needs this assessment of physical and mental health, and of medical treatment and care needs, whenever someone applies for a determination of eligibility for long-term care home admission under the Fixing Long-Term Care Act, 2021. The placement co-ordinator uses it to decide eligibility, then sends it to the homes the applicant chose so each can decide whether it can meet the applicant's care needs.

Who completes it

A physician, nurse practitioner (RN in the extended class) or registered nurse completes the whole form, including diagnoses, advance care planning, priority medications, behaviours, wounds, TB screening and devices, and signs it. Ontario Health atHome's placement co-ordinator fills in its contact section, and the applicant applies separately on form 4767-69E.

Submitting and payment

How to submit it
Return the signed form and any attachments to Ontario Health atHome at the contact the placement co-ordinator enters on page 1; when faxing, fax any additional documents with it.
Who pays
Practitioners bill OHIP fee code K038 when Ontario Health atHome requires the assessment, with no Schedule of Benefits limit; if three or more forms are medically necessary, the claim can be flagged for manual review with supporting documentation.

Good to know

  • The July 2025 edition dropped the routine chest x-ray: practitioners screen for TB symptoms and risk factors, and only applicants with new or worsening symptoms are referred for an x-ray.
  • Practitioners may attach the cumulative patient profile and tick the matching box instead of completing sections it covers; an entire medical records file is not a substitute.
  • On reassessment by the same practitioner with no change in health, only the applicant and practitioner sections are needed; a different practitioner marks Initial Assessment and completes everything.
  • A placement co-ordinator can authorize admission only if the assessment or reassessment was made within the previous three months, or after a significant change in condition.

Get the official form

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

Health Assessment - Ontario Health atHome

Évaluation de l’état de santé – Santé à domicile Ontario

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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 complete the Ontario long-term care Health Assessment Form?

A physician, a registered nurse in the extended class (nurse practitioner) or a registered nurse in the general class. The Ministry of Long-Term Care notes that physicians and nurses may both have access to the cumulative patient profile, which can be attached in place of several sections of the form.

Is the old Health Assessment Form still accepted?

Ontario Health atHome accepted the previous form until December 31, 2025. It still accepts an old-form initial assessment while the applicant's health is unchanged, but reassessments after that date use the new 4768-69E; if nothing has changed, the practitioner marks Reassessment and no change, completes the applicant and practitioner sections, and signs.

Which medications must be highlighted on the form?

The Current Medications section asks practitioners to flag priority medications: benzodiazepines, antipsychotics, other psychotropic drugs, opioids, and diuretics or antiglycemics, giving the name, purpose and other details where known. Methadone or other opioid use disorder treatment goes in the separate substance use section with the prescriber and pharmacy.