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: champlainquality@hccontario.ca
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 HCCSSmedia@hccontario.ca.
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 | Summary | Region | Last Modified | Category | File Type | File Size | 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 | Champlain | January 9, 2023 | Forms | 250 KB | champlain | forms | |||
| Authorization for Release of Personal Health Information Form | Authorization for Release of Personal Health Information Form | Champlain | September 19, 2022 | Forms | 522 KB | champlain | forms | |||
| Authorization to Collect, Use, Disclose PHI Form – Bilingual | Authorization to Collect, Use, Disclose PHI Form – Bilingual | Champlain | September 22, 2022 | Forms | 450 KB | champlain | forms | |||
| Community IV Therapy Venous Access Algorithm | Community IV Therapy Venous Access Algorithm | Champlain | September 19, 2022 | Forms | 118 KB | 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 | Champlain | September 21, 2022 | Forms | 33 KB | champlain | forms | |||
| Email Consent and Use Form – English | … | Champlain | September 22, 2022 | Forms | 362 KB | champlain | forms | |||
| Email Consent and Use Form – French | Email Consent and Use Form – French | Champlain | September 22, 2022 | Forms | 307 KB | champlain | forms | |||
| Family Managed Home Care Application Form – English | Family Managed Home Care Application Form – English | Champlain | September 22, 2022 | Forms | 356 KB | champlain | forms | |||
| Family Managed Home Care Application Form – French | Family Managed Home Care Application Form – French | Champlain | September 22, 2022 | Forms | 338 KB | champlain | forms | |||
| First Dose Parenteral Administration Form | First Dose Parenteral Administration Form | Champlain | September 19, 2022 | Forms | 554 KB | champlain | forms | |||
| Infusion Therapy – IV Remdesivir Referral Form | Infusion Therapy – IV Remdesivir Referral Form | Champlain | October 20, 2023 | Forms | 188 KB | champlain | forms | |||
| Infusion Therapy Venous Access Referral Form | Infusion Therapy Venous Access Referral Form | Champlain | September 19, 2022 | Forms | 382 KB | champlain | forms | |||
| Integrated Bruyere Outpatient and Community Stroke Rehabilitation Referral Form | Integrated Bruyere Outpatient and Community Stroke Rehabilitation Referral Form | Champlain | September 13, 2023 | Forms | 237 KB | champlain | forms | |||
| Long-Term Care Home Crisis Choice List – Bilingual | Long-Term Care Home Crisis Choice List – Bilingual | Champlain | June 20, 2023 | Forms | 400 KB | champlain | forms | |||
| Long-Term Care Home Choice List – English | Long-Term Care Home Choice List – English | Champlain | October 16, 2023 | Forms | 207 KB | champlain | forms | |||
| Long-Term Care Home Choice List – French | Long-Term Care Home Choice List – French | Champlain | October 16, 2023 | Forms | 214 KB | champlain | forms | |||
| Long-Term Care Home Short Stay Interim Choice List – English | Long-Term Care Home Short Stay Interim Choice List – English | Champlain | October 16, 2023 | Forms | 114 KB | champlain | forms | |||
| Long-Term Care Home Short Stay Interim Choice List – French | Long-Term Care Home Short Stay Interim Choice List – French | Champlain | October 16, 2023 | Forms | 106 KB | champlain | forms | |||
| Long-Term Care Home Short-Stay Respite Choice List – English | Long-Term Care Home Short Stay Respite Choice List – English | Champlain | August 28, 2023 | Forms | 156 KB | champlain | forms | |||
| Long-Term Care Home Short-Stay Respite Choice List – French | Long-Term Care Home Short Stay Respite Choice List – French | Champlain | August 28, 2023 | Forms | 553 KB | champlain | forms | |||
| LTC Counselling Checklist – English | Long-term care counselling checklist for community patients. | Champlain | October 11, 2023 | Forms | 161 KB | champlain | forms | |||
| LTC Counselling Checklist – French | Patients dans la communauté – Liste de vérification des conseils pour admission en soins de longue durée | Champlain | October 11, 2023 | Forms | 165 KB | champlain | forms | |||
| LTC Counselling Checklist for Hospital Patients – English | Long-term care counselling checklist for hospital patients. | Champlain | October 11, 2023 | Forms | 844 KB | champlain | forms | |||
| LTC Counselling Checklist for Hospital Patients – French | Liste de vérification pour les patients hospitalisés – Renseignements sur les soins de longue durée | Champlain | October 11, 2023 | Forms | 814 KB | champlain | forms | |||
| Medical Referral Form | Medical Referral Form | Champlain | September 19, 2022 | Forms | 389 KB | champlain | forms | |||
| Medical Referral Infusions Pain and Symptom Management | Medical Referral Infusions Pain and Symptom Management | Champlain | September 19, 2022 | Forms | 1 MB | champlain | forms | |||
| Negative Pressure Wound Therapy Prescription Form | Negative Pressure Wound Therapy Prescription Form | Champlain | September 19, 2022 | Forms | 525 KB | champlain | forms | |||
| Referral Form for Home and Community Care Services | Champlain referral form for home and community care services | Champlain | February 24, 2023 | Forms | 442 KB | champlain | forms | |||
| Regional Palliative Consultation Team Referral Form | Regional Palliative Consultation Team Referral Form | Champlain | September 19, 2022 | Forms | 233 KB | champlain | forms | |||
| Symptom Response Kit for End-of-Life Order Form – Champlain | Symptom Response Kit for End-of-Life Order Form – Champlain | Champlain | January 23, 2023 | Forms | 333 KB | champlain | forms | |||
| Telehomecare COVID-19 Remote Monitoring Referral Form – FR | Telehomecare COVID-19 Remote Monitoring Referral Form – FR | Champlain | September 19, 2022 | Forms | 381 KB | champlain | forms | |||
| TeleHomeCare Remote Monitoring Program Referral Form | … | Champlain | February 1, 2023 | Forms | 238 KB | champlain | forms | |||
| Telehomecare Remote Monitoring Program Referral Form-FR | … | Champlain | February 1, 2023 | Forms | 241 KB | champlain | forms |