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OHIP Form 4963-84E: Out-of-Province Prior Approval

This form asks the Ministry of Health to approve, before treatment, full payment for insured hospital or physician services a patient will receive in another Canadian province or territory. The care must be at a publicly funded hospital that can bill reciprocally or at a facility with a ministry preferred provider arrangement. The ministry sends its decision letter to the signing physician and the patient.

Who completes it

Either the attending out-of-province physician or the attending Ontario physician completes the entire form, and Part 2 (referring Ontario physician) is filled in only when an Ontario physician is involved. The patient, or a parent, guardian or attorney, signs Part 6 alongside the physician.

Submitting and payment

How to submit it
Send the completed form by fax or mail to the ministry's Out-of-Country Prior Approval Program, using the details printed on the form. Illegible forms are returned by fax for clarification.
Who pays
No physician fee is listed; an approval covers insured hospital and physician services only, not travel, accommodation, ambulance, home care, devices or take-home drugs.

Good to know

  • Bariatric surgery requests must include the recommendation of a multidisciplinary team at an Ontario Regional Assessment and Treatment Centre; cancer requests need all relevant documents, including consultation letters.
  • Diagnostic laboratory testing goes on form 4521-84 instead, and treatment needed because of a work-related accident goes to WSIB with a Health Professional's Report (Form 8).
  • The patient's health number and address must match the ministry's records or the application is returned. For inpatient care, give the expected days in hospital and the admission date.
  • Part 3 needs the out-of-province hospital's reciprocal billing number, and Part 5 asks for short- and long-term follow-up plans for patients needing ongoing long-term care.

Get the official form

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

Request for Prior Approval for Full Payment of Insured Out-of-Province (OOP) Health Services (in another province/territory)

Demande d'approbation préalable du remboursement de services de santé hors province assurés (autre province ou territoire)

Official pagePDFVersion française

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

Who signs the out-of-province prior approval form?

Two signatures are needed in Part 6: the patient or their authorized representative, and either the referring Ontario physician or the out-of-province physician. If the patient has not signed, the form asks for an explanation. Representatives of patients over 16 must provide documents such as a power of attorney.

What criteria must out-of-province treatment meet?

The service must be insured in Ontario, medically necessary and generally accepted in Ontario for a person in these circumstances, not experimental, research or a survey, and performed at a publicly funded hospital that can bill reciprocally or at a facility with a ministry preferred provider arrangement.

Is form 4963-84E available in French?

Yes. The Central Forms Repository posts English (4963-84E) and French (4963-84F) versions. The English file opens with completion instructions explaining each part, followed by the form itself, which can be filled in on screen and printed before it is faxed or mailed to the ministry.