An often overlooked form for seniors is the Co-payment application. This application is used to ensure that the senior receiving benefits is still eligible, and that they are not receiving too much assistance from the government. Here we will go over how to fill out this form, who needs to fill it out, and when it needs to be filled out. We will also provide a downloadable pdf of the blank form. The co-payment application is a necessary tool in ensuring that only those who need government assistance are given it. It can be difficult to complete, but our guide will walk you through every step of the process. Keep in mind that this form must be filled out by both the applicant and their spouse (if applicable), so make sure
Question | Answer |
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Form Name | Co Payment Application For Seniors Form |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | odb co payment form, senior copayment program, odb copayment application, odb copay form for seniors |
Ministry of Health
and
You are automatically eligible for Ontario Drug Benefits if you:
Sare 65 or older, (i.e. the first day of the month past your 65th birthday) and
Slive in Ontario, and
Shave a valid Health Card
Application
Before you begin:
1.There are two types of
Please complete this application ONLY if you believe you are eligible for the $2
2.You should complete this application for the $2
S your combined net income is less than $24,175 (for a couple)
3.If you are 65 or older and live with a spouse or partner, decide which one of you will fill out the application. The person who fills out the application will be our contact if we have to call or write for more information.
Please PRINT clearly in capital letters using a blue or black pen.
Please remember that you must both sign the application in all signature areas which are lightly shaded.
A.Tell us about you – the applicant
You must complete this section, even if you have no income.
See the Guide to Your Application for information about your net income.
Last name
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Health Number |
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Version Code* |
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Social Insurance Number |
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Telephone number |
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Which of these best describes your living situation? Mark ( X ) one box only. |
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X |
married or living with partner |
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X |
single, separated, divorced, or widowed |
Mailing address (street number, street name)
Date of birth
Y Y Y Y / M M / D D
What language do you prefer?
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X |
English |
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French |
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Net Income (see #3 in Guide) |
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$ |
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Apt. # |
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City or town |
Province |
Postal Code |
O
N
* Complete this box if there are any letters after your Health Number.
If your mailing address above is different than your residence address, give us your full residence address.
Street number and name, lot, concession or township
City or town |
Province |
Postal Code |
O
B. Tell us about your spouse or partner
N
Complete this section if you are married or living with a partner. widowed, please go to Section C.
Last name of spouse or partner
First name |
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Health Number |
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Version Code* |
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Sex |
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X |
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Social Insurance Number |
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Relationship to you |
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If you are single, separated, divorced or
Middle name
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Date of birth |
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Net Income (see #3 in Guide) |
$
,
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Total Income
Add your net income to your spouse’s or partner’s income. |
$ |
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B. Tell us about your spouse or partner (CONTINUED)
Please send us a copy of your Notice of Assessment from the Canada Revenue Agency, or other proof of income for both you and your partner.
C. Please read and sign this agreement
Make sure you and your spouse or partner sign this application in all signature areas which are lightly shaded.
By signing this application you confirm that:
Sthe information provided in this application is true, correct and complete to the best of my knowledge;
1S the Ministry of Health and
Syou will tell the Ministry of Health and
income or your spouse’s/partner’s income.
Your signature
X
Date
Y Y Y Y / M M /
D D
Your spouse’s or partner’s signature
X
Date
Y Y Y Y / M M / D D
I authorize the Canada Revenue Agency to release to the Ministry of Health and
2 Drug Benefit Act, and will not be disclosed to any other person or organization without my approval, except as required or permitted by law. This authorization is valid for the most recently available of the two taxation years prior to signing this consent and each subsequent consecutive taxation year for which assistance under the Ontario Drug Benefit Act may be requested and determined. I understand that, if I wish to withdraw this consent, I may do so at any time by writing to the Ontario Drug Benefit Program, 5700 Yonge Street, 3rd Floor, Toronto ON M2M 4K5
Applicant
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Signature of applicant or applicant’s representative |
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Please mark ( X ) appropriate box to identify above signatory, and attach supporting documents, as appropriate. |
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applicant |
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X applicant’s Guardian of Property |
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X applicant’s Guardian of the person |
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applicant’s Attorney under continuing power of attorney |
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applicant’s Attorney under power of attorney for personal care |
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If the signature above is NOT that of the applicant, print the signatory’s information. |
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Applicant’s Spouse/Partner |
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Signature of spouse/partner or representative |
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Please mark ( X ) appropriate box to identify above signatory, and attach supporting documents, as appropriate. |
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spouse / partner |
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X spouse’s/partner’s Guardian of Property |
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X spouse’s/partner’s Guardian of the person |
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spouse’s/partner’s Attorney under continuing power of attorney |
X |
spouse’s/partner’s Attorney under power of attorney for personal care |
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If the signature above is NOT that of the applicant’s spouse/partner, print the signatory’s information. |
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First name |
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Please check again that you / your representative and your spouse / partner / their representative have signed in all areas which are lightly shaded. If any signatures are missing, we will have to return your application.
When you have completed the application:
1.Make sure that you / your representative and your spouse / partner / their representative have signed in all areas which are lightly shaded.
2.Collect the documents you’ll need for proof of income (see #3 of the enclosed guide for a list of the documents).
3.If applicable, collect any supporting documents you will need (see section above)
4.Send everything to us in the return envelope. The address is Ontario Drug Benefit Program, Ministry of Health and
5.We’ll notify you by mail once we’ve processed your application.
This information is collected under the authority of the Personal Health Information Protection Act, 2004, S.O. 2004, c.3, Sched. A (PHIPA) and Section 13 of the Ontario Drug Benefit Act, R.S.O. 1990, c.O.10. This information is collected for the purpose of administering the Ontario Drug Benefit Program. It may be used and disclosed in accordance with PHIPA, as set out in the Ministry of Health and
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