Champlain
Information and Referral
310-2222
Toll-free:1-800-538-0520
Fax:613-745-6984
TTY:711
Visit Champlain Healthline
To request home and community care services, please complete this online referral form, or call us at 1-800-538-0520 (toll-free) or 613-745-5525.
Champlain Office Locations
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Ottawa (Corporate Office and Mailing Address)
4200 Labelle St,
Suite 100
Ottawa, ON, K1J 1J8
Toll-free: 1-866-902-5446
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Bell’s Corners
301 Moodie Dr.
Suite 105
Ottawa, ON, K2H 9C4
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Cornwall
709 Cotton Mill St.
Cornwall, ON, K6H 7K7
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Hawkesbury
119 Main St. East
Suite 101
Hawkesbury, ON, K6A 1A1
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Pembroke
1100 Pembroke St. East
Pembroke, ON, K8A 6Y7
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Renfrew
850 O’Brien Rd.
Unit 8
Renfrew, ON, K7V 3Z4
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Winchester
530 Fred St.
Suite D, PO Box 209
Winchester, ON, K0C 2K0
Compliments and Concerns?
Please share your feedback with your care coordinator. You may also share compliments or concerns in the following ways:
Email: [email protected]
Phone: 1-844-454-1322
Newsroom and Media Relations
Visit our newsroom for more information on news and events.
For all media-related enquiries, please contact [email protected].
For non-media-related enquiries about Home and Community Care Support Services and to serve you best, please visit the Contact Us page to access additional contact information.
Accessibility Documents
Publications
- When Death Occurs at Home
- Welcome Kit – English
- Telehomecare Remote Monitoring COPD HF Patient Information
- Telehomecare Remote Monitoring COPD HF Physician Information
- Home First
- Long-Term Care Home List
- MAID FAQ
- MAID Information for Physicians and Nurses – English
- Primary Care Resource
- Regional Palliative Consultation Team Brochure
Forms
| Title | Excerpt | Categories | Link | hf:doc_tags | hf:doc_categories | hf:file_type |
|---|---|---|---|---|---|---|
| Application for Determination of Eligibility for LTC – English | Application for Determination of Eligibility for Long-Term Care – English | Forms | champlain | forms | ||
| Authorization for Release of Personal Health Information Form | Authorization for Release of Personal Health Information Form | Forms | champlain | forms | ||
| Authorization to Collect, Use, Disclose PHI Form – Bilingual | Authorization to Collect, Use, Disclose PHI Form – Bilingual | Forms | champlain | forms | ||
| Community IV Therapy Venous Access Algorithm | Community IV Therapy Venous Access Algorithm | Forms | champlain | forms | ||
| Demande de détermination d’admissibilité pour une admission en foyer de soins de longue durée | Demande de détermination d’admissibilité pour une admission en foyer de soins de longue durée | Forms | champlain | forms | ||
| Email Consent and Use Form – English | … | Forms | champlain | forms | ||
| Email Consent and Use Form – French | Email Consent and Use Form – French | Forms | champlain | forms | ||
| Family Managed Home Care Application Form – English | Family Managed Home Care Application Form – English | Forms | champlain | forms | ||
| Family Managed Home Care Application Form – French | Family Managed Home Care Application Form – French | Forms | champlain | forms | ||
| First Dose Parenteral Administration Form | First Dose Parenteral Administration Form | Forms | champlain | forms | ||
| Infusion Therapy – IV Remdesivir Referral Form | Infusion Therapy – IV Remdesivir Referral Form | Forms | champlain | forms | ||
| Infusion Therapy Venous Access Referral Form | Infusion Therapy Venous Access Referral Form | Forms | champlain | forms | ||
| Integrated Bruyere Outpatient and Community Stroke Rehabilitation Referral Form | Integrated Bruyere Outpatient and Community Stroke Rehabilitation Referral Form | Forms | champlain | forms | ||
| Long-Term Care Home Crisis Choice List – Bilingual | Long-Term Care Home Crisis Choice List – Bilingual | Forms | champlain | forms | ||
| Long-Term Care Home Choice List – English | Long-Term Care Home Choice List – English | Forms | champlain | forms | ||
| Long-Term Care Home Choice List – French | Long-Term Care Home Choice List – French | Forms | champlain | forms | ||
| Long-Term Care Home Short Stay Interim Choice List – English | Long-Term Care Home Short Stay Interim Choice List – English | Forms | champlain | forms | ||
| Long-Term Care Home Short Stay Interim Choice List – French | Long-Term Care Home Short Stay Interim Choice List – French | Forms | champlain | forms | ||
| Long-Term Care Home Short-Stay Respite Choice List – English | Long-Term Care Home Short Stay Respite Choice List – English | Forms | champlain | forms | ||
| Long-Term Care Home Short-Stay Respite Choice List – French | Long-Term Care Home Short Stay Respite Choice List – French | Forms | champlain | forms | ||
| LTC Counselling Checklist – English | Long-term care counselling checklist for community patients. | Forms | champlain | forms | ||
| LTC Counselling Checklist – French | Patients dans la communauté – Liste de vérification des conseils pour admission en soins de longue durée | Forms | champlain | forms | ||
| LTC Counselling Checklist for Hospital Patients – English | Long-term care counselling checklist for hospital patients. | Forms | champlain | forms | ||
| LTC Counselling Checklist for Hospital Patients – French | Liste de vérification pour les patients hospitalisés – Renseignements sur les soins de longue durée | Forms | champlain | forms | ||
| Medical Referral Form | Medical Referral Form | Forms | champlain | forms | ||
| Medical Referral Infusions Pain and Symptom Management | Medical Referral Infusions Pain and Symptom Management | Forms | champlain | forms | ||
| Negative Pressure Wound Therapy Prescription Form | Negative Pressure Wound Therapy Prescription Form | Forms | champlain | forms | ||
| Referral Form for Home and Community Care Services | Champlain referral form for home and community care services | Forms | champlain | forms | ||
| Regional Palliative Consultation Team Referral Form | Regional Palliative Consultation Team Referral Form | Forms | champlain | forms | ||
| Symptom Response Kit for End-of-Life Order Form – Champlain | Symptom Response Kit for End-of-Life Order Form – Champlain | Forms | champlain | forms | ||
| Telehomecare COVID-19 Remote Monitoring Referral Form – FR | Telehomecare COVID-19 Remote Monitoring Referral Form – FR | Forms | champlain | forms | ||
| TeleHomeCare Remote Monitoring Program Referral Form | … | Forms | champlain | forms | ||
| Telehomecare Remote Monitoring Program Referral Form-FR | … | Forms | champlain | forms |