Physician Referral Form?

This physician referral form may be completed and submitted online (see below) OR downloaded and faxed to our office at (416) 398-6262. With a referral note, OHIP provides partial coverage for the hearing assessment. The OHIP fee schedule does NOT include an Audiology Consultation Fee. Due to this partial coverage, there is a $47 fee not covered by OHIP. Without a referral note, the fee for a hearing assessment is $79.

There is no charge for routine hearing tests for children under the Infant Hearing Program (IHP). The IHP provides services to children from birth to 6 years of age with permanent hearing loss, or for those who are at risk for permanent hearing loss.

DOWNLOAD REFERRAL FORM?

Referring Physician First (required)

Referring Physician First

Billing No. (required)

Physician Fax No. (required)

Physician Phone No.

Patient First Name

Patient Last Name

Patient Email Address (required)

Patient Birth Date

Patient Phone Number

OHIP & Version Code

Patient Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Comprehensive Hearing Test (battery of tests will vary with age)Auditory Brainstem Response TestTinnitus Assessment & Counselling (private pay)Hearing Aid ConsultationHearing Aid Check & RepairCustom-made noise & swimplugsOtherCheck All That Apply

Please specify any special considerations (e.g. developmental concerns, etc.)