|Classification / Identification:|
| ||Form Number:||014-4953-64E||Edition date: ||2015/12 |
| ||Title:||Healthy Smiles Ontario – Application|
| ||Ministry:||Health and Long-Term Care|| || |
| ||Branch/ABC:||Public Health|| || |
| ||Program:||Public Health|| || |
| ||Purpose of Form:||Main application form for the core services stream of the Healthy Smiles Ontario program. This form applies to: (A) applicants that have a valid SIN and have filed statement of income or tax return with CRA; OR (B) applicants who do not have a valid SIN or have not filed taxes with CRA. The Guarantor Section on the Application Form is required to support registration and eligibility adjudication.|| || |
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