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Adobe PDF Adobe PDF document  Seniors Co-Payment Program ApplicationThe 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.Fill, Print & Save1422.0 kb

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Classification / Identification:
 Form Number:014-3233-87Edition date: 2021/05 
 Title:Seniors Co-Payment Program Application
 Ministry:Health  
 Branch/ABC:Drug Programs Delivery Branch  
 Program:Drug Programs Delivery Branch  
 Purpose of Form:For low income seniors to apply for the Seniors Co-Payment Program. This form cannot be downloaded with most smart phones or iPads. Refer to the FAQ for more information. If you need a copy of the form, contact the Seniors Co-Payment Program at toll-free 1-888-405-0405.  
 Ordering Information:Submit completed order request form (form # 014-0350-93) to OSSDistribution@ontario.ca (preferred option) or fax to 416-679-8192.

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