Ministry of Health
and Long-Term Care
Notification of High Cost Service
Requirements
High Intensity Needs Fund
I.
Long-Term Care Home Information
Name of Home
Address - number, street name
City or Town
Contact Name - first name, last name
Telephone number
Fax number
(
(
Compliance Advisor- first name, last name
II.
)
Postal Code
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)
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Service Area Office
LHIN
Resident Information
Resident Name - first name, last name
Check one box only:
Initial Assessment
Initial Assessment Date (yyyy/mm/dd)
Final Notification Date (yyyy/mm/dd)
Change in Need Date (yyyy/mm/dd)
OR
Change in Assessment (attach Initial Assessment form)
III. High Intensity Needs Category
A. Complete Nutritional Supplement Support
I. Training
C. TPN Supplies & Equipment
E. Equipment & Supplies to support vital processes
for pain management
F. Treatment/Transfer Equipment & Supplies
D. Wound Care Products/Supplies
G. Transportation for Dialysis
L. Oxygen Supplies & Equipment
H. Preferred Accommodation
M. Assessment
B. Enteral Nutrition Support
J. Supplementary Staffing
K. Ostomy Supplies
IV. Initial Assessment / Re-Assessment
Description of diagnosis - resident care needs and frequency of administration. Please see instructions on reverse for additional requirements.
V.
Equipment and Supplies Required (check all that are required)
Equipment
Supplies
Apnea Monitor
TENS
Enteral Nutrition Support
Bariatric Transferring Equipment
Therapeutic Surfaces
Other (specify):
Hydration Fluids (IV/hypodermoclysis)
Bladder Irrigation Equipment
Total Parenteral Nutrition
Nebulizers
Complete Nutritional Supplement Support (liquid)
Negative Pressure Wound Therapy
Tracheostomy Supplies
Pumps (for Feeds, Pain, or Intravenous)
Wound Dressings (specify in Part IV)
Suction Catheters
Other (specify):
Specify any equipment purchases that exceed $2,000: (include product name and cost)
VI. Estimated Duration of Need
Check one box only:
Less than 1 month
1-3 months
3-6 months
6 months-1 year
One-Time Expenditure
Indefinite (specify reason):
VII. Assessor Information
Assessment conducted by - first name, last name
Title
Date (yyyy/mm/dd)
VIII. Confirmation
I confirm that the information provided on this form is accurate and to the best of my knowledge is sufficient to indicate that the equipment, services and/or
supplies are entitled to funding and are being provided for a resident who is defined as eligible for the equipment, services and/or supplies in accordance with
the High Intensity Needs Fund Manual.
Signature
Name - first name, last name
Title
Date (yyyy/mm/dd)
This information is collected under the authority of section 36 of the Personal Health Information Protection Act, 2004, S.O. 2004, c. 3, Sched. A, for the purpose of administering the High Intensity Needs Funding
program. It may be used and disclosed in accordance with the Personal Health Information Protection Act, 2004, as set out in the Ministry of Health and Long-Term Care “Statement of Information Practices”,
which may be accessed at www. health.gov.on.ca. If you have any questions concerning the collection of this information, please contact: Manager, Access and Privacy Office, Ministry of Health and Long-Term
Care, 5700 Yonge St., 5th Floor, Toronto, Ontario, M2M 4K5
IX. Approvals (complete only if verbal approval has been acquired from the Compliance Advisor)
Check if verbal pre-approval has been acquired from the Compliance Advisor.
Name of Compliance Advisor - first name, last name
Date of Approval (yyyy/mm/dd)
Notes
Ministry Use Only
Approved by - first name, last name
Date (yyyy/mm/dd)
Notes
4489-69 (07/07)
© Queen’s Printer for Ontario, 2007
Time (HH:MM)
Notification of High Cost Service Requirements - Instructions for Completion
Eligibility Criteria
General Instructions
Residents must meet criteria 1, 2 AND 3 AND 4a) OR 4b) OR
4c) to be eligible for support from the High Intensity Needs
Fund.
Pre-approval from your Compliance Advisor is required for any of the
following items and where the resident meets the criteria listed above:
 The acquisition of any one item over $2,000 (excluding surface
rental);
 Therapeutic surfaces for Stage II wounds;
 Transfer equipment for the morbidly obese;
 Preferred accommodation;
 Training for long-term care home staff;
 Transportation to and from treatment sites for dialysis; and,
 Supplementary staffing
1.
Resident is in a long-term care home
(excludes convalescent care residents).
AND
2.
Resident requires support from one of the following high
needs categories as defined in the High Intensity Needs
Fund Manual:
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Complete nutritional supplement support
Enteral nutrition support
Total parenteral nutrition
Wound care products/supplies
Equipment/supplies to support vital process or pain
management
Treatment/transfer equipment and supplies
Transportation for dialysis
Preferred accommodation
Completing the Form
I.
II.
Supplementary staffing
Ostomy supplies
Oxygen supplies and equipment
Assessments
AND
4a. Resident would require transfer to hospital without this
support.
OR
4b. Resident would be unable to be discharged from hospital
without this support.
The following situations will require re-approval from a Compliance
Advisor:
 Approval needs to be extended beyond the initial duration
identified during the original assessment.
 A change in a resident's condition that modifies initial care
requirements indicated in Section IV.
 Wound care treatment required beyond the initial 90 day
duration.
 Changes in transportation requirements.
 Preferred accommodation required beyond 30 days.
 Supplementary staffing/1:1 staffing required beyond 72 hours.
III.
OR
4c. Resident is at risk for causing or contributing to significant
harm to self or others.
IV.
4489-69 (07/07)
© Queen’s Printer for Ontario, 2007
Resident Information
Provide the name of the resident, the initial assessment date and
the final notification date.
 Indicate whether the assessment is the initial or a re-assessment
due to a change in need.
 Re-assessments due to change in need must be accompanied
by the original approved Notice of High Cost Service
Requirements.

Training
Resident has identified risk factors for significant
functional decline. Identified areas of risk may include but
are not limited to: behaviours, nutrition, renal, bladder,
pain, respiratory, bowel and wounds.
V.
High Intensity Needs Category
 Check off the appropriate High Needs category(s).
 For Wound Care, check off ‘D’ only.
Initial Assessment/ Re-Assessment
 Provide a description of the care requirements and goal.
 List the frequency of administration.
Specify wound stage, sites, size and all supplies required.
If the wound is Stage II, please explain the specific circumstances.
List interventions for one-to-one staffing.
If palliative, specify the analgesic order and effect.
If additional space is required, please attach a separate page.
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Equipment and Supplies Required
Check off the applicable equipment and/or supplies required.
For wound care, detail all supplies required in Section IV.
Any individual equipment purchases that exceed $2,000 should be detailed
including the cost and type of equipment.
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Estimated Duration of Need
Check the applicable duration of need.
Provide a reason when the duration identified is 'Indefinite'.
Please refer to the High Intensity Needs Fund Manual for timeframe
restrictions on specific categories.
VI.

AND
3.
Home Information
Provide the name and address of the LTC home including the
name, phone number and fax number of the contact person.
 Provide the LHIN, Service Area Office and name of the
Compliance Advisor.
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VII. Assessor Information
 Assessments are to be conducted by any healthcare professional who has
the clinical expertise to develop an appropriate treatment plan for the
resident. For example, a Registered Dietitian would assess a resident for
Enteral Nutrition Support.
 The name and title of the professional performing the assessment is required.
VIII. Confirmation of Need
 The signature of a LTC home staff member who has clinical knowledge of the
resident is required. Staff could include Director of Care, Charge Nurse,
Physician, etc.
 This section must not be completed by the same individual who has
completed Section VII.
IX.
Approvals
In certain circumstances, the Compliance Advisor may provide verbal
approval to expedite the delivery of care to residents.
 Where verbal approval has been acquired, the name of the Compliance
Advisor, date and time of approval should be provided.

Returning the Completed Form
Your completed form should be faxed to your Service Area Office to the attention of
your Compliance Advisor.
To ensure efficient processing of the form, please review that the form is complete
and includes all required signatures.