What the 4367-84 is for
The New Patient Declaration documents that a patient enrolling with you didn’t have a family physician, and why. It goes with the Patient Enrolment and Consent to Release Personal Health Information form, and only applies once that enrolment form is signed. The ministry relies on it at audit to confirm a new patient fee was claimed for a patient who was really new to you and your group.
The OMA’s Q-code guide lists the New Patient Declaration among the forms needed for the New Patient Fee for patients with an abnormal FIT or increased colorectal cancer risk, enrolled through ColonCancerCheck. Patients enrolled after a hospital stay use a different form, the Unattached Patient Declaration.
Who completes it
The patient completes the declaration, Section A and Section C for themselves. A parent or guardian, or a dependent adult’s attorney for personal care, completes Section B and Section C instead. The enrolling physician signs Section D.
Usually the front desk hands the patient the enrolment form and this declaration together at the first appointment, the patient fills them in on paper in the waiting room, and the physician signs both before they’re filed. In Medulla, you send Sections A to C to the patient over a secure link before the visit. They tick their reasons, enter their health number and sign from any device, and their answers land on the PDF you sign Section D on.
How to fill in your part
Check the patient’s part
Before you sign, check that the declaration box matches who is signing: myself, children of whom they are parent or guardian, or dependent adults. At least one reason must be ticked: the family physician moved, the patient moved, the physician is unavailable through illness, death, retirement or a change of practice type, or the patient hasn’t had or felt the need for a family physician until now. Health numbers must be complete for each person listed.
Section D: Physician Signature and Date
By signing, you declare that the patient isn’t presently your patient, or to your knowledge a patient of any physician in your primary care group. You also declare that no child listed is a newborn of one of your existing enrolled or non-enrolled patients, or one of your group’s. You agree to provide ongoing care from the date of the document and to keep it on file in your primary office. Print your name, sign and date it.
Common reasons it fails an audit
- A patient who was already seen by you or your group before enrolment.
- A newborn of an existing patient listed in Section B.
- No reason ticked in the declaration, or no patient signature in Section C.
- A date that doesn’t match the enrolment and consent form or the fee claim.
- More than two dependants listed on one form.
- The form missing from the office file when the ministry asks for it.
Submitting and who pays
Don’t mail the form. File it in your primary office location with the enrolment and consent form, and give the patient their copy of the enrolment form. The ministry asks for copies only for verification. Any new patient fee is claimed through OHIP under your enrolment model’s rules, with the same service date as the forms.