What the Form 3 is for
The Act lets municipalities and approved First Nation bands provide homemaking and visiting nursing services. An application is made on Form 1, with a consent to inspect assets on Form 2. When the application is for a nurse, Regulation 634 requires a physician’s certificate on Form 3. The certificate states why the person needs a registered nurse at home and what the nurse will do. It isn’t a referral to Ontario Health atHome, which runs the provincial home care program separately.
Who completes it
The attending physician completes the whole form and signs it. The applicant completes Forms 1 and 2, which are separate forms.
How to fill in Form 3
1. Applicant
The applicant’s name and address.
2. Purpose of the nursing services
Tick whether visiting nursing will let the applicant remain at home, or make possible their return home from a hospital or other institution. For a return home, name the hospital or institution and give its address.
3. Nursing procedures, visits and period
Tick the procedures: bed bath, catheterization, dressings, enemas, hypodermic injection, intravenous infusion, irrigation, or other, specified. Then give the visit frequency, daily, a number per week, or a number per month, and the period in days, weeks or months. Give a realistic schedule and an end point, since the period sets how long the services are requested for.
4. Physician
Print your name and address, then sign and date.
Common reasons it’s delayed
- No procedures ticked, or “other” with nothing specified.
- No visit frequency or no period.
- A return home from hospital with no institution named.
- Sent alone, without the applicant’s Form 1 and Form 2.
Submitting and who pays
Form 3 goes with the applicant’s Form 1 and Form 2 to the welfare administrator of their municipality, region or approved band. The administrator decides the application and assesses whether the applicant can pay the fees. Ontario reimburses the municipality or band for 80% of the net cost of services to a person in need.