|Classification / Identification:|
| ||Form Number:||014-3266-54E||Edition date: ||2008/06 |
| ||Title:||Application for Reduction of Assessed Co-payment Fees|
| ||Ministry:||Health and Long-Term Care|| || |
| ||Branch/ABC:||Acute Services Division|| || |
| ||Program:||Acute Services|| || |
| ||Purpose of Form:||This form is to be used for a patient who is seeking a reduction to the co-payment or for whom a reduction is sought further to the factors set out in section 10 of Reg. 552 under the Health Insurance Act.|| || |
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