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Adobe PDF Adobe PDF document  Application for Reduction of Assessed Co-payment FeesThe file you are about to download will ONLY work properly if opened with an Adobe Reader 10 or later client. Please do not open this file in a browser.View & Print38.0 kb

Form Classification
Classification / Identification:
 Form Number:014-3266-54EEdition 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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