Mandatory Special Necessities (MSN)
Benefit Request
Name of individual requiring items/services:
Team #:Member ID:
Ontario Works (OW) may provide funding for transportation needed to obtain medical treatment. Costs for diabetic supplies, surgical supplies, and
dressings are also covered. Verification of the medical necessity is required. While we appreciate your cooperation in completing this form, we are
unable to accept responsibility for any fee attached to providing this documentation.
This section may be completed by Ontario licensed physicians, Registered Nurses in the Extended Class and psychologists (for addiction related travel only).
Medical Transportation
Physician/Facility Name Location
# of Visits
per month
Required From
(mm/yy)
Required Until
(mm/yy)
Type of transportation required:
Taxi Private Vehicle
This section may be completed by Ontario licensed physicians or Registered Nurses in the Extended Class (where a physician has assessed the need).
Diabetic Supplies
Glucometer Required?
Yes No
Lancets Number required per day:
Insulin Syringe Number required per day:
Needle Tips Number required per day:
1 4 Other
please specify number:
please specify number:
Other41
please specify number:
Other41
This section may be completed by Ontario licensed physicians or Registered Nurses in the Extended Class (where a physician has assessed the need). Ontario Works will
provide for the costs of surgical supplies and dressings not otherwise provided for. For OW purposes, surgical supplies and dressings are considered to be those
supplies prescribed by a licensed Ontario physician, and required as a direct result of a surgical, radiological, or medical procedure or disease.
Surgical Supplies
Item Number Required
Period Required
(daily/weekly/etc)
Required From
(mm/yy)
Required Until
(mm/yy)
/ per
/ per
/ per
Date:
Physician or Health Professional's Signature
Name of Physician or Health Professional:
Physician / Health Care Professional please fax completed forms to 519.482.1632 or mail to address below.
Form completed by:
Phone :
County of Huron Social Services - Ontario Works
77722D London Road, RR 5 Clinton, ON N0M 1L0 | Telephone: 519.482.8505 | Toll Free 1.888.371.5718 | Fax 519.482.1632
INTENDED FOR USE BY RESIDENTS OF HURON COUNTY ONLY
