Please complete Sections 1, 2, 3 and 5, including your signature.
Under Section 3, Advanced Funding by Third Party Agency/Society, enter Hope Air number code 0207 and Hope Air address noted below. Tick the box to direct the NHTG Program to direct funding to Hope Air.
Request your specialist complete section 6 with their signature.
Send the completed and signed form by post to: 110 Eglinton Ave E, Suite 501, Toronto, Ontario, M4P 2Y1
Once received, Hope Air will submit the application to the Ministry of Health for partial reimbursement.
