Step 2 of 5

Application Type

Is this request for a new NHTG Application or to provide updated information for an existing NHTG Application?(required)

The Northern Health Travel Grant (NHTG) Program helps defray travel related expenses of eligible Northern Ontario residents seeking medical specialist services or procedures at a ministry funded health care facility (e.g. CAT scan). Ministry travel grants are based on the distance to the nearest medical specialist or ministry funded health care facility able to provide the required health care services without a delay that would compromise the patient’s health.

Please note:

  • Please consider Telemedicine instead of travel: Ontario Telemedicine Network (OTN) supports almost every clinical specialty and may be an alternative to having patients travel. The OTN referral form is available here
  • Ensure your most current name and address information have been provided to the Ministry of Health (MOH). Your name and address information, as registered with the MOH will be used for identity assurance purposes. If your address information provided on this application does not match your health number records, this application will be used to update your records.
  • Patient must complete and submit a new, separate application for each round trip.
  • Your NHTG application must be received by the MOH within twelve (12) months from the date of service.
  • Requests for re-consideration / re-assessment of applications must be received within twelve (12) months from the date of payment, the date of grant denial or the date the claim is returned to a client.
  • Tickets and/or itineraries for travel, showing who travelled, dates of travel, destination round trip and fare amount paid, must be provided for travel by air, bus or rail for patient and/or companion. Travel itineraries are acceptable if accumulated airline travel credits were used.

NOTE: The Northern Health Travel Grant (NHTG) program does not cover expenses for meals or taxi services. Do not submit these receipts as part of your application. Gas receipts should be kept for 12 months if we require proof of travel for audit purposes.

  • If several patients / their companions travel together in the same car, only one travel grant will be paid per round trip.

Eligibility Criteria for a Patient Travel Grant - Patient must satisfy all of the following:

  1. Must be a resident of Northern Ontario in the districts of Algoma, Cochrane, Kenora, Manitoulin, Nipissing, Parry Sound, Rainy River, Sudbury, Thunder Bay or Timiskaming and be an OHIP-insured person on the date the service is provided.
  2. Must be referred within Ontario or to Manitoba for specialist health care or health care facility-based procedures that are insured services under the Health Insurance Act.
  3. Must have travelled at least 100 km (one way road distance) to obtain the required service from their area of residence to the location of the nearest medical specialist / health care facility referred to in Ontario or Manitoba.
  4. Must be referred for specialty medical services. “Specialty medical services” means medical services rendered by the following:
    • a medical specialist who is certified by The Royal College of Physicians and Surgeons of Canada (RCPSC),
    • a Winnipeg (Manitoba) physician enrolled on the Manitoba Health Specialist Register and permitted to bill as a specialist,
    • a physician who holds a specialist certificate of registration issued by the College of Physicians and Surgeons of Ontario (CPSO) in a recognized medical or surgical specialty other than family or general practice,
    • a general practitioner with a GP Focused Practice designation with the CPSO,
    • a non-specialist Dentist participating in the Cleft Lip/Palate Program or the Ontario Seniors Dental Care Program,
    • a ministry-funded health care facility.

    To verify a specialist’s certification online, go to CPSO website (link) and follow the instructions. Contact the NHTG Program to find out if a particular healthcare facility is considered a ministry-funded healthcare facility.

  5. Must confirm that travel costs are not covered by another program/organization such as WSIB, NIHB (Non-Insured Health Benefits Program for eligible First Nations and Inuit people) or private insurance (e.g., third-party liability). Contact the NHTG Program for additional details.

Eligibility for Accommodation Allowance – A patient must meet all of the following criteria in order to be eligible for the accommodation allowance:

  1. The patient meets the travel grant eligibility criteria set out above: number 1, 2, 3, 4, and 5.
  2. The patient has submitted original accommodation receipts (e.g., official hotel/lodging receipts) to prove a lodging expense was incurred. For patients under 18 years of age, an accommodation/lodging receipt may be in the name of the parent/guardian.

Note: Ministry-funded healthcare facilities include those providing services the MOH directly and indirectly funds.

Accommodation Allowance of $175-$1,150 is paid, based on the number of medically-necessary lodging nights:

  • $175 one night
  • $350 for two nights
  • $475 for three nights
  • $1,025 for four to seven nights
  • $1,150 for eight or more nights

Information About Guardians and Substitute Decision Makers (SDM)

If the patient is a child under 16 years of age, the child’s parent / guardian with custody may complete and sign the form on behalf of the child. If the patient is 16 or older but incapable of consenting on his / her own behalf, a Substitute Decision Maker (SDM) may complete and sign the form on the patient’s behalf. SDM’s include patient’s:

  • Guardian who has authority to make a decision on behalf of patient;
  • Attorney for Personal Care who has authority to make a decision on behalf of patient;
  • Representative appointed by Consent and Capacity Board with authority to give consent;
  • Spouse/Partner;
  • Child/Parent or children’s aid society or other person legally entitled to give/refuse consent;
  • Parent with only right of access;
  • Brother/sister;
  • Other relative.

For more specific information on SDMs, please contact the NHTG Program directly (see Contact Information – NHTG Program at the bottom of the Instructions Section).

Assistive Devices Program (ADP) (For Providers)

For Assistive Devices Program (ADP) applications where patient is referred for fitting, adjustments or repairs for ADP approved orthotics and prosthetics, both the following criteria must be met:

  1. vendor has an ADP authorizer registration number; and
  2. travel is for an approved ADP device.

Eligibility Criteria for a Companion Travel Grant – Companion grant may be paid when all of the following are met:

  1. Patient meets above travel grant eligibility criteria.
  2. Companion must be 16 years of age or older.
  3. Companion must travel with the patient and pay a fare if travel is by air, rail or bus. If travel is round trip by automobile, one half of the grant may be paid to the patient and the other half paid to the companion.

NHTG Internal Review Committee

Note: If you have additional information to support reconsideration of your application by the NHTG Internal Review Committee, please forward the information to the NHTG office at:

Northern Health Travel Grant
Internal Review Committee
Claims Service Branch
159 Cedar Street, 7th Floor
Sudbury, ON P3E 6A5

If there are exceptional medical circumstances surrounding your treatment trip, please provide a letter of support from your northern referring provider explaining those medical circumstances.

Submit your application to:

MOH – NHTG Program
159 Cedar St, 7th Flr
Sudbury ON P3E 6A5

Contact Information – NHTG Program:

Office hours are 8:30 a.m. to 5:00 p.m., Monday to Friday. Closed holidays.

For more information, call 1-800-262-6524. Or go to Northern Health Travel Grant Program Website

Third-Party Agency Involvement

Was funding provided by an NHTG-Approved Third-Party Agency for this trip?(required)

Submitter Type

Who is completing and submitting this application?(required)

NOTE: Either a Patient / Substitute Decision Maker or an NHTG Approved Third-Party Agency can complete this Online Application.If a Third-Party Agency is the “Submitter”, they must upload a signed “Northern Health Travel Grant Patient Consent for Third-Party Agency Request Form.”

Advance Funding by Third Party Agency/Society

NOTE: Third Party Agencies must be approved by the Northern Health Travel Grant program. All approved Third Party Agencies are listed in the drop-down menu below. If the agency you are seeking is not included in this list, please contact the NHTG program: 1-800-262-6524.

All payments directed to Third Party Agencies must be paid by electronic funds transfer (EFT).

(Format must be A#A #A#)

Patient Consent for Third-Party Agency Submissions

NOTE: All Third-Party Agencies must obtain patient consent in order to submit an NHTG Application. Please access the “Northern Health Travel Grant Patient Consent for Third-Party Agency Request” form at the following link.

Northern Health Travel Grant Patient Consent for Third-Party Agency Request Form

The patient for whom this application applies to must complete the form in its entirety and sign.Please attach the signed, completed form to this online application submission using the “Attach File” button below.

Attachments

NOTE: Please DO NOT take pictures of documents to include as attachments as picture files (JPG, PNG, etc.) are typically large file sizes that in accumulation will exceed the file size limits (13 MB for all attachments for this application).

For support on how to scan documents and create PDFs using your smartphone, please access the links below.
How to Scan Documents on your iPhone and create PDFs
How to Scan Documents on your Android Device and create PDFs

To attach supporting documents, click the "Add File (+)" button. Most common file types (e.g., Word, PDF, JPEG files) are acceptable excluding video or audio files due to their file size. The total file size of all attachments is limited to 13 MB.

Attach File 1

Patient Information

Please ensure you enter the following information accurately, as it appears on your Ontario Health Card.

Address Associated with Ontario Health Card Number (NOTE: This address will be used for identity assurance of the patient)

Address information

Please ensure you enter the residential address that is associated with your Ontario Health Card Number. This information will be used by the ministry to validate the identity of the patient for which the Northern Health Travel Grant is being submitted.

Note: If you have not updated the current address for the patient with the ministry, please contact ServiceOntario prior to submitting this application:

ServiceOntario
Change my address, Service Ontario
1-800-267-8097

(if necessary, continue to select the Postal Code Lookup button until your correct street name is shown or complete the address fields with the correct information)

(Format must be 10 digits)

Date of Service

Please indicate the “Date of Service” for services provided by the Specialty-Service Provider for this trip.

Type of Transportation

What type of transportation was used to travel for specialty-service care?

What type of transportation was used to travel home from specialty-service care?

Please attach travel receipts to prove a commercial carrier travel expense was incurred. Tickets and/or itineraries for travel, showing who travelled, dates of travel, destination round trip and fare amount paid, must be provided for travel by air, bus or rail for patient and/or companion. Travel itineraries are acceptable if accumulated airline travel credits were used.
For patients under 18 years of age, an accommodation/lodging receipt may be in the name of the parent/guardian.

Support for creating travel receipt attachmentsNOTE: Please DO NOT take pictures of documents to include as attachments as picture files (JPG, PNG, etc.) are typically large file sizes that in accumulation will exceed the file size limits (13 MB for all attachments for this application).

TIP: Locate your travel receipts in your email inbox. The commercial carrier company (i.e. airline) will often include your receipt as a PDF attachment. If the email itself is the “receipt”, you can create a PDF of the email by selecting “Print” and the option “Print to PDF.” You will then be asked to save to a location on your computer and will be able to access the file to upload to this application as an attachable file from there.

To attach supporting documents, click the "Add File (+)" button. Most common file types (e.g., Word, PDF, JPEG files) are acceptable excluding video or audio files due to their file size. The total file size of all attachments is limited to 13 MB.

Attach File 1

Eligible for reimbursement from another organization/program.

Are your travel costs eligible for reimbursement from another program?

Alternate Mailing Address

Do you wish to enter an Alternate Mailing Address that is different than the one listed above that is associated with your Ontario Health Card?(required)
(if necessary, continue to select the Postal Code Lookup button until your correct street name is shown or complete the address fields with the correct information)

(Format must be 10 digits)

Companion Information

Did you travel with a companion?(required)
(if necessary, continue to select the Postal Code Lookup button until your correct street name is shown or complete the address fields with the correct information)

(Format must be 10 digits)

(Example: name@example.com)

(Example: name@example.com)

Type of Transportation

What type of transportation was used to travel for specialty-service care?

What type of transportation was used to travel home from specialty-service care?

Please attach travel receipts to prove a commercial carrier travel expense was incurred. Tickets and/or itineraries for travel, showing who travelled, dates of travel, destination round trip and fare amount paid, must be provided for travel by air, bus or rail for patient and/or companion. Travel itineraries are acceptable if accumulated airline travel credits were used.
For patients under 18 years of age, an accommodation/lodging receipt may be in the name of the parent/guardian.

Support for creating travel receipt attachmentsNOTE: Please DO NOT take pictures of documents to include as attachments as picture files (JPG, PNG, etc.) are typically large file sizes that in accumulation will exceed the file size limits (13 MB for all attachments for this application).

TIP: Locate your travel receipts in your email inbox. The commercial carrier company (i.e. airline) will often include your receipt as a PDF attachment. If the email itself is the “receipt”, you can create a PDF of the email by selecting “Print” and the option “Print to PDF.” You will then be asked to save to a location on your computer and will be able to access the file to upload to this application as an attachable file from there.

To attach supporting documents, click the "Add File (+)" button. Most common file types (e.g., Word, PDF, JPEG files) are acceptable excluding video or audio files due to their file size. The total file size of all attachments is limited to 13 MB.

Attach File 1

Payment Preference

NHTG payments are delivered more efficiently using direct deposit of funds to your bank account.

If you choose to receive your grant payment via direct deposit, you must submit a bank-issued direct deposit form with your grant application.

NOTE: Your bank statement will show a payment from “NOTS.”

If you chose not to complete this section, or select “No” below, the payment will be defaulted to a cheque payment via regular mail.

Patient Enrolment for Direct Deposit

Do you wish to receive your grant via direct deposit?(required)
Is this your first time signing up for Direct Deposit with the Northern Health Travel Grant program?(required)
Do you wish to update banking information that you submitted previously?(required)

Please attach your Payroll Direct Deposit Form or Void Cheque, below

NOTE: Please DO NOT take pictures of documents to include as attachments as picture files (JPG, PNG, etc.) are typically large file sizes that in accumulation will exceed the file size limits (13 MB for all attachments for this application).

Attachment Support Tip:
If you conduct your banking online, you will be able to download a PDF version of a void cheque from your online banking site. This option is usually located under “Accounts”. You will also be able to locate the option to download a Void Cheque by utilizing your online banking “Help” feature.

To attach supporting documents, click the "Add File (+)" button. Most common file types (e.g., Word, PDF, JPEG files) are acceptable excluding video or audio files due to their file size. The total file size of all attachments is limited to 13 MB.

Attach File 1

Travel Companion Enrolment for Direct Deposit

Do you wish to receive your grant via direct deposit to your bank account?
If “Yes” is selected, attach a Payroll Direct Deposit Form or Void Cheque with the application.(required)

Please attach your Payroll Direct Deposit Form or Void Cheque, below

NOTE: Please DO NOT take pictures of documents to include as attachments as picture files (JPG, PNG, etc.) are typically large file sizes that in accumulation will exceed the file size limits (13 MB for all attachments for this application).

Attachment Support Tip:
If you conduct your banking online, you will be able to download a PDF version of a void cheque from your online banking site. This option is usually located under “Accounts”. You will also be able to locate the option to download a Void Cheque by utilizing your online banking “Help” feature.

To attach supporting documents, click the "Add File (+)" button. Most common file types (e.g., Word, PDF, JPEG files) are acceptable excluding video or audio files due to their file size. The total file size of all attachments is limited to 13 MB.

Attach File 1

Attachments

Specialty-Service Provider Form Attachment

The Specialty-Service Provider Form is to be completed by a Specialty-Service Provider who has provided an OHIP-insured service in a ministry-funded healthcare facility to a patient who is eligible for a Northern Health Travel Grant (NHTG).

A Specialty-Service Provider Form must be submitted for each NHTG application.

The Specialty-Service Provider Form can be accessed at the following link:

Specialty-Service Provider Form

NOTE: Please DO NOT take pictures of documents to include as attachments as picture files (JPG, PNG, etc.) are typically large file sizes that in accumulation will exceed the file size limits (13 MB for all attachments for this application).

For support on how to scan documents and create PDFs using your smartphone, please access the links below.

How to Scan Documents on your iPhone and create PDFs

How to Scan Documents on your Android Device and create PDFs

To attach supporting documents, click the "Add File (+)" button. Most common file types (e.g., Word, PDF, JPEG files) are acceptable excluding video or audio files due to their file size. The total file size of all attachments is limited to 13 MB.

Attach File 1

Accommodation Receipts and/or Additional Attachments

Did you incur accommodation expenses for this treatment trip, or would you like to attach any additional information to this application?(required)

Please attach Accommodation Receipts and/or Additional Attachments (i.e. official hotel/lodging receipts) to prove a lodging expense was incurred. For patients under 18 years of age, an accommodation/lodging receipt may be in the name of the parent/guardian.
Support for creating lodging receipt attachments
NOTE: Please DO NOT take pictures of documents to include as attachments as picture files (JPG, PNG, etc.) are typically large file sizes that in accumulation will exceed the file size limits (13 MB for all attachments for this application).
TIP: Locate your accommodation receipts in your email inbox. The hotel will often include your receipt as a PDF attachment. If the email itself is the “receipt”, you can create a PDF of the email by selecting “Print” and the option “Print to PDF.” You will then be asked to save to a location on your computer and will be able to access the file to upload to this application as an attachable file from there.

To attach supporting documents, click the "Add File (+)" button. Most common file types (e.g., Word, PDF, JPEG files) are acceptable excluding video or audio files due to their file size. The total file size of all attachments is limited to 13 MB.

Attach File 1

Authorization for NHTG Application

Notice: The ministry cannot process your application unless you (and your companion, if applicable) provide the personal information required. The ministry needs this information for the proper administration of the NHTG Program and will use and may disclose it for the purpose of determining your eligibility and processing your application. If you (and your companion, if applicable) do not consent to the ministry’s collection, use and/or disclosure of this information, the ministry cannot process your application. For further information, please contact the ministry by phone at 1-800-262-6524.

Patient / Guardian / Substitute Decision Maker / Third-Party Agency Acknowledgement

(Example: name@example.com)

(Example: name@example.com)

I have the legal authority to make this request as I am (please select ONE of the following options):

Address Update(required)

Alternate Mailing Address

(if necessary, continue to select the Postal Code Lookup button until your correct street name is shown or complete the address fields with the correct information)

(Format must be 10 digits)

Address Update(required)

Alternate Mailing Address

(if necessary, continue to select the Postal Code Lookup button until your correct street name is shown or complete the address fields with the correct information)

(Format must be 10 digits)

Attestation

Purpose:The purpose of this application is to submit updates or additional information related to a previously submitted Northern Health Travel Grant (NHTG) application.

Please note:

  • Patient must complete and submit a new, separate application for each round trip.
  • Your NHTG application must be received by the Ministry of Health (MOH) within twelve (12) months from the date of service.
  • Requests for re-consideration / re-assessment of applications must be received within twelve (12) months from the date of payment, the date of grant denial or the date the claim is returned to a client.
  • Tickets and/or itineraries for travel, showing who travelled, dates of travel, destination round trip and fare amount paid, must be provided for travel by air, bus or rail for patient and/or companion. Travel itineraries are acceptable if accumulated airline travel credits were used.

Eligibility for Accommodation Allowance – A patient must meet all of the following criteria in order to be eligible for the accommodation allowance:

  1. The patient has travelled at least 100 km (one way road distance) to obtain the required OHIP insured service from their area of residence to the location of the nearest medical specialist / health care facility referred to in Ontario or Manitoba.
  2. The patient has submitted original accommodation receipts (e.g. official hotel / lodging receipts) to prove a lodging expense was incurred. For patients under 18 years of age, an accommodation / lodging receipt can be in the name of the parent / guardian.

Accommodation Allowance of $175-$1,150 is paid, based on the number of medically-necessary lodging nights:

  • $175 one night
  • $350 for two nights
  • $475 for three nights
  • $1,025 for four to seven nights
  • $1,150 for eight or more nights

Information About Guardians and Substitute Decision Makers (SDM)

If the patient is a child under 16 years of age, the child’s parent / guardian with custody may complete and sign the form on behalf of the child. If the patient is 16 or older but incapable of consenting on his / her own behalf, a Substitute Decision Maker (SDM) may complete and sign the form on the patient’s behalf. SDM’s include patient’s:

  • Guardian who has authority to make a decision on behalf of patient;
  • Attorney for Personal Care who has authority to make a decision on behalf of patient;
  • Representative appointed by Consent and Capacity Board with authority to give consent;
  • Spouse/Partner;
  • Child/Parent or children’s aid society or other person legally entitled to give/refuse consent;
  • Parent with only right of access;
  • Brother/sister;
  • Other relative.

For more specific information on SDMs, please contact the NHTG Program directly (see Contact Information – NHTG Program at the bottom of the Instructions Section).

Contact Information – NHTG Program:

Office hours are 8:30 a.m. to 5:00 p.m., Monday to Friday. Closed holidays.

For more information, call 1-800-262-6524. Or go to the Northern Health Travel Grant Program Website

Application Number

Please enter the “Application Number” that was provided to you via email confirmation for the successful submission of an NHTG Online Application Form by the Patient or Third-Party Agency connected to this NHTG Application.

NOTE: If you are unable to find this email, please try searching your email inbox using the patient name. Be sure to check your “Junk Mail” inbox, as well. If you are still having issues, please contact the NHTG Program by calling 1-800-262-6524.

Third-Party Agency Involvement

Would you like to provide updates to the Third-Party Agency Information?(required)

Advance Funding by Third Party Agency/Society

NOTE: Third Party Agencies must be approved by the Northern Health Travel Grant program. All approved Third Party Agencies are listed in the drop-down menu below. If the agency you are seeking is not included in this list, please contact the NHTG program: 1-800-262-6524.

All payments directed to Third Party Agencies must be paid by electronic funds transfer (EFT).

(Format must be A#A #A#)

Attachments

The patient for whom this application applies to must complete the form in its entirety and sign.Please attach the signed, completed form to this online application submission using the “Attach File” button below.

NOTE: Please DO NOT take pictures of documents to include as attachments as picture files (JPG, PNG, etc.) are typically large file sizes that in accumulation will exceed the file size limits (13 MB for all attachments for this application).

For support on how to scan documents and create PDFs using your smartphone, please access the links below.
How to Scan Documents on your iPhone and create PDFs
How to Scan Documents on your Android Device and create PDFs

Northern Health Travel Grant Patient Consent for Third-Party Agency Request Form

NOTE: All Third-Party Agencies must obtain patient consent in order to submit an NHTG Application. Please access the “Northern Health Travel Grant Patient Consent for Third-Party Agency Request” form at the following link.

To attach supporting documents, click the "Add File (+)" button. Most common file types (e.g., Word, PDF, JPEG files) are acceptable excluding video or audio files due to their file size. The total file size of all attachments is limited to 13 MB.

Attach File 1

Patient Information

Would you like to provide updates to the Patient Information?(required)

Please ensure you enter the following information accurately, as it appears on your Ontario Health Card.

Address Associated with Ontario Health Card Number (NOTE: This address will be used for identity assurance of the patient)

Address information

Please ensure you enter the residential address that is associated with your Ontario Health Card Number. This information will be used by the ministry to validate the identity of the patient for which the Northern Health Travel Grant is being submitted.

Note: If you have not updated the current address for the patient with the ministry, please contact ServiceOntario prior to submitting this application:

ServiceOntario
Change my address, Service Ontario
1-800-267-8097

(if necessary, continue to select the Postal Code Lookup button until your correct street name is shown or complete the address fields with the correct information)

(Format must be 10 digits)

Date of Service

Please indicate the “Date of Service” for services provided by the Specialty-Service Provider for this trip.

Type of Transportation

What type of transportation was used to travel for specialty-service care?

What type of transportation was used to travel home from specialty-service care?

Please attach travel receipts to prove a commercial carrier travel expense was incurred. Tickets and/or itineraries for travel, showing who travelled, dates of travel, destination round trip and fare amount paid, must be provided for travel by air, bus or rail for patient and/or companion. Travel itineraries are acceptable if accumulated airline travel credits were used.
For patients under 18 years of age, an accommodation/lodging receipt may be in the name of the parent/guardian.

Support for creating travel receipt attachmentsNOTE: Please DO NOT take pictures of documents to include as attachments as picture files (JPG, PNG, etc.) are typically large file sizes that in accumulation will exceed the file size limits (13 MB for all attachments for this application).

TIP: Locate your travel receipts in your email inbox. The commercial carrier company (i.e. airline) will often include your receipt as a PDF attachment. If the email itself is the “receipt”, you can create a PDF of the email by selecting “Print” and the option “Print to PDF.” You will then be asked to save to a location on your computer and will be able to access the file to upload to this application as an attachable file from there.

To attach supporting documents, click the "Add File (+)" button. Most common file types (e.g., Word, PDF, JPEG files) are acceptable excluding video or audio files due to their file size. The total file size of all attachments is limited to 13 MB.

Attach File 1

Eligible for reimbursement from another organization/program

Are your travel costs eligible for reimbursement from another program?

Alternate Mailing Address

Would you like to add or update an Alternate Address?(required)
(if necessary, continue to select the Postal Code Lookup button until your correct street name is shown or complete the address fields with the correct information)

(Format must be 10 digits)

Companion Information

Would you like to provide updates to the Companion Information?(required)
(if necessary, continue to select the Postal Code Lookup button until your correct street name is shown or complete the address fields with the correct information)

(Format must be 10 digits)

(Example: name@example.com)

(Example: name@example.com)

Type of Transportation

What type of transportation was used to travel for specialty-service care?

What type of transportation was used to travel home from specialty-service care?

Please attach travel receipts to prove a commercial carrier travel expense was incurred. Tickets and/or itineraries for travel, showing who travelled, dates of travel, destination round trip and fare amount paid, must be provided for travel by air, bus or rail for patient and/or companion. Travel itineraries are acceptable if accumulated airline travel credits were used.
For patients under 18 years of age, an accommodation/lodging receipt may be in the name of the parent/guardian.

Support for creating travel receipt attachmentsNOTE: Please DO NOT take pictures of documents to include as attachments as picture files (JPG, PNG, etc.) are typically large file sizes that in accumulation will exceed the file size limits (13 MB for all attachments for this application).

TIP: Locate your travel receipts in your email inbox. The commercial carrier company (i.e. airline) will often include your receipt as a PDF attachment. If the email itself is the “receipt”, you can create a PDF of the email by selecting “Print” and the option “Print to PDF.” You will then be asked to save to a location on your computer and will be able to access the file to upload to this application as an attachable file from there.

To attach supporting documents, click the "Add File (+)" button. Most common file types (e.g., Word, PDF, JPEG files) are acceptable excluding video or audio files due to their file size. The total file size of all attachments is limited to 13 MB.

Attach File 1

Payment Preference

Would you like to provide updates to the Payment Preference?(required)

Patient Enrolment for Direct Deposit

Do you wish to receive your grant via direct deposit?(required)
Is this your first time signing up for Direct Deposit with the Northern Health Travel Grant program?(required)
Do you wish to update banking information that you submitted previously?(required)

Please attach your Payroll Direct Deposit Form or Void Cheque, below

NOTE: Please DO NOT take pictures of documents to include as attachments as picture files (JPG, PNG, etc.) are typically large file sizes that in accumulation will exceed the file size limits (13 MB for all attachments for this application).

Attachment Support Tip:
If you conduct your banking online, you will be able to download a PDF version of a void cheque from your online banking site. This option is usually located under “Accounts”. You will also be able to locate the option to download a Void Cheque by utilizing your online banking “Help” feature.

To attach supporting documents, click the "Add File (+)" button. Most common file types (e.g., Word, PDF, JPEG files) are acceptable excluding video or audio files due to their file size. The total file size of all attachments is limited to 13 MB.

Attach File 1

Travel Companion Enrolment for Direct Deposit

Do you wish to receive your grant via direct deposit to your bank account?
If “Yes” is selected, attach a Payroll Direct Deposit Form or Void Cheque with the application.(required)

Please attach your Payroll Direct Deposit Form or Void Cheque, below

NOTE: Please DO NOT take pictures of documents to include as attachments as picture files (JPG, PNG, etc.) are typically large file sizes that in accumulation will exceed the file size limits (13 MB for all attachments for this application).

Attachment Support Tip:
If you conduct your banking online, you will be able to download a PDF version of a void cheque from your online banking site. This option is usually located under “Accounts”. You will also be able to locate the option to download a Void Cheque by utilizing your online banking “Help” feature.

To attach supporting documents, click the "Add File (+)" button. Most common file types (e.g., Word, PDF, JPEG files) are acceptable excluding video or audio files due to their file size. The total file size of all attachments is limited to 13 MB.

Attach File 1

Attachments

Do you wish to add a Specialty-Service Provider Form to this application?(required)

Specialty-Service Provider Form Attachment

The Specialty-Service Provider Form is to be completed by a Specialty-Service Provider who has provided an OHIP-insured service in a ministry-funded healthcare facility to a patient who is eligible for a Northern Health Travel Grant (NHTG).

A Specialty-Service Provider Form must be submitted for each NHTG application.

The Specialty-Service Provider Form can be accessed at the following link:

Specialty-Service Provider Form

To attach supporting documents, click the "Add File (+)" button. Most common file types (e.g., Word, PDF, JPEG files) are acceptable excluding video or audio files due to their file size. The total file size of all attachments is limited to 13 MB.

Attach File 1
Do you wish to add Accommodation Receipts and/or Additional Attachments to this application?(required)

Accommodation Receipts and/or Additional Attachments

Please attach Accommodation Receipts and/or Additional Attachments (i.e. official hotel/lodging receipts) to prove a lodging expense was incurred.

For patients under 18 years of age, an accommodation/lodging receipt may be in the name of the parent/guardian.

To attach supporting documents, click the "Add File (+)" button. Most common file types (e.g., Word, PDF, JPEG files) are acceptable excluding video or audio files due to their file size. The total file size of all attachments is limited to 13 MB.

Attach File 1

Authorization for NHTG Application

Notice: The ministry cannot process your application unless you (and your companion, if applicable) provide the personal information required. The ministry needs this information for the proper administration of the NHTG Program and will use and may disclose it for the purpose of determining your eligibility and processing your application. If you (and your companion, if applicable) do not consent to the ministry’s collection, use and/or disclosure of this information, the ministry cannot process your application. For further information, please contact the ministry by phone at 1-800-262-6524.

Patient / Guardian / Substitute Decision Maker / Third-Party Agency Acknowledgement

(Example: name@example.com)

(Example: name@example.com)

I have the legal authority to make this request as I am (please select ONE of the following options):

Address Update(required)

Alternate Mailing Address

(if necessary, continue to select the Postal Code Lookup button until your correct street name is shown or complete the address fields with the correct information)

(Format must be 10 digits)

Address Update(required)

Alternate Mailing Address

(if necessary, continue to select the Postal Code Lookup button until your correct street name is shown or complete the address fields with the correct information)

(Format must be 10 digits)

Attestation

Summary

Note: To make changes to the information below, please click the “Back” button (at the top of this page) to access previous pages or “Edit Section” to make corrections.

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