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Application for Pregnancy and
Parental Leave Benefits (for Physicians)
Ministry of Health
and Long-Term Care
Guidelines and Q&As
Application Instruction
Taking a Leave
Pregnancy leave must start, at the earliest, 5 weeks before the expected due date and, at the latest, 8 weeks after the birth or hospital
discharge of the child.
Parental leave may be taken at any time after the birth of the child or after the adopted child has come into the custody, care and control of the
parent for the first time; however, the parental leave must be completed within 36 weeks of the date the baby is born or discharged from hospital
or the adopted child has come into the custody, care and control of the parent for the first time.
Submitting an Application
Pregnancy Leave Only or Pregnancy and Parental Leave: An application for pregnancy leave must be submitted no later than 8 weeks after
the birth of the child or the date the child is discharged from the hospital. You may apply for your parental leave at the same time.
Parental Leave Only: An application for parental leave only must be submitted no later than 28 weeks from the date the child is discharged
from the hospital or the date the adopted child is placed in the custody of the parent for the first time.
Submit your application with ALL required documentation by:
email to: [email protected]
fax to: 416 327-7519
mail to: Ministry of Health and Long-Term Care
Pregnancy and Parental Leave Benefit Program
1075 Bay Street, Suite 301
Toronto ON M7A 0A5
Direct your questions by:
Email to:
[email protected]
Telephone to: 416 212-6212
Application Package
To apply for pregnancy and/or parental leave, you must submit documents as listed below.
Before the Leave:
•
•
All physicians must complete Part 1 - Application and Part 2 - Consent and Declaration of this application package.
•
Physicians receiving income through an Alternate Payment Plan (APP), Alternate Funding Plan (AFP), Academic Health Science Centre
(AHSC) AFP, primary care agreement, or from an employer or paying agency must complete a Part 3 - Medical Professional Income
Confirmation form. One form is required for each source of income. A Part 3 - Medical Professional Income Confirmation form is not
required for income earned while on a residency program.
A letter or certificate from your attending physician or midwife confirming the expected date of birth of your child.
During the Leave:
• All physicians must submit a Form A - Declaration of Earned Income by the 28th day of each month while on leave, unless a declaration of
zero income for the duration of the leave(s) was submitted in the first month of the leave. Payment will be delayed until the next month if
Form A - Declaration of Earned Income is not received by that time.
•
If you work in a capitation based model and will be claiming deductions from your capitation payments for locum coverage, a letter from
the locum stating the period of time he or she will be covering for you and the weekly amount you will be paying for that coverage.
After the Birth or Placement in Custody of an Adopted Child:
•
•
•
All physicians must submit a Form B - Notification of Birth after the child is born or when the adopted child is place in custody for the first
time as well as a copy of the Birth Registration or Certificate of Adoption.
Physicians taking parental leave only must submit a Form B - Notification of Birth at the start of the leave; payments will not be made
until Form B is received.
The Birth Registration may be any one of the following:
i)
Certified statement of live birth
ii) Written confirmation from the attending physician/midwife
iii) Division Registrar's Statement
iv) Notice of Birth Registration
v) Copy of Birth Certificate
4874-77E (2014/04)
© Queen's Printer for Ontario, 2014
Disponible en français
Page 1 of 6
Application for Pregnancy and
Parental Leave Benefits (for Physicians)
Ministry of Health
Pregnancy and Parental
and Long-Term Care Leave Benefit Program
1075 Bay Street, Suite 301
Toronto ON M7A 0A5
Part 1 - Application
Applications for pregnancy leave must be submitted no later than 8 weeks after the birth of the child or the date the child is discharged from the
hospital. Applications for parental leave only must be submitted no later than 28 weeks from the date the child is discharged from the hospital
or the date the adopted child is placed in the custody of the parent for the first time. Scan and email your application to [email protected] or
mail to the above address.
Physician Information
Last Name
CPSO Licence Number
Home Mailing Address
Unit Number
Street Number
First Name
Street Name
City/Town
Office Address
Unit Number
Email Address
OHIP Billing Number
Province
Postal Code
ON
Street Number
Telephone Number
Street Name
PO Box
City/Town
Province
Postal Code
ON
I hereby certify the information provided in this Application and all other documents that form part of my application package are true and accurate and that I will
abide by the terms of the Pregnancy and Parental Leave Benefit Program policies as described in the "Pregnancy and Parental Leave Benefit Program Guidelines".
Signature of Physician
Date (yyyy/mm/dd)
I am applying for (check all that apply and specify start date yyyy/mm/dd)
Pregnancy Leave (specify start date)
Parental Leave (specify start date)
Expected Date of Birth or Placement of Adopted Child (yyyy/mm/dd)
In the 26 weeks immediately preceding the start date of my pregnancy or parental leave,
I was practicing medicine in Ontario, providing services remunerated by the Ministry through the OHIP or
providing insured clinical services remunerated by an employer.
I completed a residency in Ontario.
No
No
In the 12 months prior to my leave start date, I practiced medicine in Ontario
I am in a primary care model (specify i.e. FHO, FHG, CCM, etc.)
from (yyyy/mm/dd)
and I am on
Yes
Yes
to (yyyy/mm/dd)
Select one
Pre-Leave Income Declaration
List your gross income from all sources for OHIP insured services rendered during the 12-month period prior to the start of your leave.
Physicians in primary care models, specialists in an APP, AFA, AHSC, AFP, salaried physicians and physicians receiving " other medical
professional income" must submit a Part 3 - Medical Professional Income Confirmation form for each source of income.
Fee for Service Income: Direct billings excluding technical fees
$
Primary Care Model Physicians: All payments received through primary care agreements, i.e. billings, base capitation payments,
$
bonuses, premiums, and other incentives
Specialists: All payments of any kind received under any APP, AFA, or AHSC AFP
$
Salaried Physicians: Income from an employer for insured clinical services
$
Residents: Income earned as a resident
$
All Physicians: Other medical professional income including sessional payments, stipends or supplements received from a hospital, community agency/
organization, LHIN, long-term care facility, ministry, government agency or in the case of specialists, received under a Primary Health Care Agreement.
1.
$
2.
$
3.
$
Total
$
4874-77E (2014/04)
Continue to Declaration and Consent on Page 3 . . . . .
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Part 2 - Declaration and Consent
Last Name
First Name
I acknowledge that in order to receive benefits under the Pregnancy and Parental Leave Benefit Program, it is my personal responsibility to meet the
deadlines and conditions set out in this document.
1. Declaration
1.
I declare that:
a) I am licensed by the College of Physicians and Surgeons to practice medicine in Ontario; and
b) I reside in Ontario; and
c) In the 26 weeks immediately preceding the start date of my pregnancy and/or parental leave:
i)
I was practicing medicine in Ontario, providing services remunerated by the Ministry of Health and Long-Term Care (the Ministry) through the
Ontario Health Insurance Program (OHIP) or providing insured clinical services remunerated by an employer;
OR
ii) I completed a residency in Ontario; and
d) I have not entered into an agreement with the Ministry that provides any other similar pregnancy or parental leave benefits under that agreement.
2.
I understand that if I am or will be receiving benefits from Employment Insurance (EI) or maternity/pregnancy and/or parental benefits from my
employer at any time while I am on pregnancy and/or parental leave, I am only entitled to receive a top up or supplemental payment from the
Pregnancy and Parental Leave Benefit Program that is the difference between the amount received from my employer and/or EI up to the amount
payable by the Pregnancy and Parental Leave Benefit Program, providing all other conditions of the Program are met.
3.
I declare I have read and agree to abide by the parameters set out in the Pregnancy and Parental Leave Benefit Program Guidelines and Application
Package.
2. Consent:
The Ministry is authorized to collect the personal information requested in this form and Forms A and B for the purposes of administering the Pregnancy and
Parental Leave Benefit Program under s.4.1 (1) of the Health Insurance Act, R.S.O. 1990, c.H.6, s. 39 of the Freedom of Information and Protection of Privacy
Act, R.S.O. 1990, c. F.36, s.6 (1) of the Ministry of Health and Long-Term Care Act, R.S.O. 1990, c.M.26 and s36 (1) (a) of the Personal Health Information
Protection Act, 2004. The personal information will be used to assess, verify and monitor eligibility for participation in the Pregnancy and Parental Leave Benefit
Program and for payment. It may also be used to collect statistical information to report on the program, research and evaluate the program parameters and
outcomes.
I understand that, in order for the Ministry to administer the Program, the Ministry must know all medical professional income earned over the 12-month period
immediately preceding the start date of the pregnancy and/or parental leave or, if I have not practised medicine in Ontario for 12 months, since I started practising
medicine in Ontario up to the start date of the pregnancy and/or parental leave and while I am receiving Program benefits, including: fee for service; an Alternate
Funding Arrangement (AFA), such as an Alternate Payment Plan Agreement, Alternate Funding Plan Agreement, Academic Health Science Centre Alternate
Funding Plan Agreement, primary-care agreement; an employer; any other medical professional source; as well as benefits from EI or pregnancy/maternity and/or
paternity benefits from an employer.
I will provide consent and direct the Administrator of my AFA, representative from my paying agency, or employer to disclose to the Ministry the total amount paid
to me under that agreement during the 12-month period immediately preceding the start date of the pregnancy and/or parental leave or, if I have not practised
medicine in Ontario for 12-months, since I started practising medicine in Ontario up to the start date of the pregnancy and/or pregnancy leave and all amounts
paid to me during the period I am on pregnancy and/or parental leave.
I hereby consent to the Ministry using this information, including my declarations and any other information relating to my medical professional income. I consent
to this disclosure during the 12-month period immediately preceding the start date of the pregnancy and/or parental leave or, if I have not practised medicine in
Ontario for 12-months, since I started practising medicine in Ontario up to the start date of the pregnancy and/or pregnancy leave as well as while I am in receipt
of benefits under the Program, for the purposes of monitoring the Program.
I understand that I may withhold my consent to the collection of the personal health information relevant to my participation in the pregnancy leave benefit
component of the Program, but that such withdrawal of consent will preclude my participation in the pregnancy portion of the Pregnancy and Parental Leave
Benefit Program.
I understand that if I receive more money from the Program than the amount to which I am entitled for that week, the Ministry may deduct an amount equal to the
excess from any future benefits paid to me under the Program. If the Ministry is unable to recover the whole of the excess by deduction from future payments
under the Program, the Ministry may recover the balance of the excess by any lawful means including, but not limited to, deduction from any amounts otherwise
payable to me by OHIP or under an AFA.
I certify that the information provided in this application package and all related forms is true and accurate.
Physician Signature:
Print Form
4874-77E (2014/04)
Date:
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Page 3 of 6
Part 3 - Medical Professional Income Confirmation (as required)
Physicians receiving income through an Alternate Funding Arrangement (AFA) (i.e. APP, AFP, AHSC AFP, primary care agreement), or from
an employer or paying agency must complete a Medical Professional Income Confirmation form for each source of income, except for income
earned while in a residency program.
Section 1 - Physician Information (to be completed by physician applying for pregnancy or parental leave benefits)
Last Name
First Name
CPSO Licence Number
Leave Start Date (yyyy/mm/dd)
OHIP Billing Number
By signing below, I consent that the Administrator of my AFA, representative from my paying agency or employer may disclose to the Ministry of
Health and Long-Term Care the total amount paid to me under that agreement during the 12-month period immediately preceding the start date
of my pregnancy and/or parental leave.
Date (yyyy/mm/dd)
Signature of Physician
Section 2 - Employer, AFA, Physician Lead or Paying Agency Information
(to be completed by AFA Administrator / Paying Agency Representative / Employer)
Please check one:
AFA
Employer
Other (specify) ►
Name of Employer, AFA or Paying Agency
Name of the Administrator / Representative
Unit Number
Street Number
Street Name
City/Town
PO Box
Province
Telephone Number
Fax Number
Postal Code
ON
Email Address
Income Information:
Gross income earned by the physician during the 12-month period prior to the start date of the pregnancy or parental leave:
Date from (yyyy/mm/dd)
Gross Income $
Date to (yyyy/mm/dd)
Salaried Physician Only: Will the physician receive pregnancy / maternity and/or parental benefits through your organization?
Number of Weeks
Starting Date (yyyy/mm/dd)
Amount of benefit
No
Yes (provide details) ►
per week
$
Will the physician be receiving any earnings or portions of a salary during the period of his/her leave?
No
Yes (provide details) ▼
Signature Administrator / Representative
Date (yyyy/mm/dd)
If you have any questions regarding this form, please contact the PPLBP Administrator at 416 212-6212 or [email protected]
All information collected on these forms may be used as necessary by the Ministry of Health and Long-Term Care for proper administration of the government-funded
physician Pregnancy and Parental Leave Benefit Program, including assessing eligibility to participate and receive benefits from this program and calculation of
benefit entitlement. The Ministry of Health and Long-Term Care may use the statistical information to report on the program, research and evaluate the program
parameters and outcomes. If you require further information about this please contact: Ministry of Health and Long-Term Care 1075 Bay St., Suite 301, Toronto ON
M7A 0A5. Tel: 416 212-6212.
Print Form
4874-77E (2014/04)
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Page 4 of 6
Form A Declaration of Earned Income
Ministry of Health
Pregnancy and Parental
and Long-Term Care Leave Benefit Program
1075 Bay Street, Suite 301
Toronto ON M7A 0A5
You must submit this form by the 28th day of every month you are on leave even if your earnings are zero, unless you have made a
declaration of zero income for the duration of your leave(s). No payment can be issued without a Declaration of Earned Income form. Please
scan and email your Declaration of Earned Income form to [email protected] or fax to 416 327-7519.
Last Name
First Name
CPSO Licence Number
OHIP Billing Number
This document discloses all my gross income for OHIP insured services I provided and Employment Insurance (EI) and/or employer
benefits I am or will be receiving.
Signature of Physician
Date (yyyy/mm/dd)
I will be taking my parental leave in non-consecutive weeks
No
Yes
I will be earning income during my pregnancy and/or parental leaves
No
Yes
I will be receiving EI and / or employer benefits
Employment Insurance (EI) Benefits
No
Yes (specify below ▼)
Start Date (yyyy/mm/dd)
End Date (yyyy/mm/dd)
Employer Benefits
Weekly Amount
Start Date (yyyy/mm/dd)
End Date (yyyy/mm/dd)
Weekly Amount
Date you anticipate returning to work (yyyy/mm/dd)
Income Earned by Week*
Week 1
* Calendar weeks are calculated
from Sunday to Saturday (yyyy/mm/dd)
Week 2
Week 3
Week 4
Week 5
From
From
From
From
From
To
To
To
To
To
Income1 (List gross payments from every source of income)
Payment for Locum Coverage (to be completed by Primary Care Model Physicians only).
Other Maternity / Pregnancy / Parental Benefits2 :
EI Benefits
Employer Benefits
1
Income includes fee for services billings and :
a. Specialists: all payments of any kind received under any APP, AFA or AHSC AFP
b. Primary Care Model Physicians: all payments received through primary-care agreements, i.e. billings, base capitation payments, bonuses, premiums, and other incentives
c. Other medical professional income: sessional payments, stipends or supplements received from a hospital, community agency/organization, LHIN, long-term care facility, ministry,
government agency or in the case of specialists, received under a Primary Health Care Agreement
d. Salary from an employer for insured clinical services and income earned while a resident.
2
Other Maternity/Pregnancy/Parental Benefits: If you are receiving maternity/pregnancy and/or parental leave benefits from your employer or through EI, you are
entitled to receive a top-up or supplemental payment from the Pregnancy and Parental Leave Benefit Program that is the difference between the amount
received from the employer and/or EI and the amount payable under the Pregnancy and Parental Leave Benefit Program. This top-up payment will be
applied throughout your leave no matter when you start receiving benefit payments from EI and/or your employer.
Print Form
4874-77E (2014/04)
Clear Form
Page 5 of 6
Form B Notification of Birth
Ministry of Health
Pregnancy and Parental
and Long-Term Care Leave Benefit Program
1075 Bay Street, Suite 301
Toronto ON M7A 0A5
Pregnancy or Pregnancy and Parental Leave: You must submit this form before the end of your leave.
Parental Leave Only: You must submit this form at the start of your leave to initiate payments.
Please scan and email your Notification of Birth form to [email protected] or fax to 416 327-7519.
Last Name
First Name
CPSO Licence Number
OHIP Billing Number
Start Date of Pregnancy Leave (yyyy/mm/dd)
Start Date of Parental Leave (yyyy/mm/dd)
Date of Child Birth (yyyy/mm/dd)
Date of Child's Discharge from Hospital (yyyy/mm/dd)
Adoption Only
Date child was placed in your custody for the first time (yyyy/mm/dd)
Before the end of your pregnancy or parental leave, you must submit a copy of your child's birth registration or adoption
certificate.
Birth Registration may be any one of the following:
• Certified Statement of Live Birth
• Written confirmation from the attending physician / midwife
• Division Registrar's Statement
• Notice of Birth Registration
• Birth Certificate
Signature of Physician
Print Form
4874-77E (2014/04)
Date (yyyy/mm/dd)
Clear Form
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