Patient Management Program - HCAI
Part 3
Other Insurance Information
Type in any other insurer; i.e.. Ministry of Health, Extended Health Care Plan, or any others.
Part 4
Signature of Health Practitioner
Complete the Signature of Health Practitioner information. Only practitioners listed below are permitted
to completion this section:
Chiropractor
Family / General Practitioner
Occupational Therapist
Optometrist
Physiotherapist
Psychologist
Pathologist
Dentist
Nurse Practitioner
Ophthalmologist
Other Medical / Surgical Practitioner
Psychiatrist
Speech-Language
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