How to authorize ICHSC physician affiliation — and autofill 014-4900-85 with my-id.ca
Declare physician affiliation for an ICHSC without retyping credentials
Physicians affiliating with Integrated Community Health Services Centres repeat legal name, CPSO registration, practice address, and ICHSC licensee identifiers on every affiliation authorization. This guide is an example of storing them once in my-id.ca.
Official form and source
Start from the official source and always use the current version — form numbers and links can change:
- Service page: Forms for community surgical and diagnostic centres — ontario.ca
- Form (Central Forms Repository): Physician Affiliation Authorization and Declaration of Professional Standing for ICHSCs — 014-4900-85
What this form is about
Form 014-4900-85 is the Physician Affiliation Authorization and Declaration of Professional Standing for ICHSCs, used when a physician affiliates with an Integrated Community Health Services Centre — confirm ministry requirements on ontario.ca.
Before you start: what to gather
- Physician full legal name and CPSO registration number.
- Practice address and contact phone or email.
- ICHSC licensee legal name and facility identifiers.
- Declaration of professional standing — confirm current attestation wording on ontario.ca.
Confirm the current process on ontario.ca.
How my-id.ca makes it faster
- Save it once. Store your physician and ICHSC organization names, addresses, and registration numbers in your my-id.ca profile.
- Keep documents ready. Upload supporting documents to my-id.ca Files so you are not searching at form time.
- Autofill the form. Use the my-id.ca Chrome extension on a web form, or fill a PDF from your saved profile inside my-id.ca.
- Review and submit yourself through the official channel.
Why do it in my-id.ca
Related Ontario forms repeat the same personal details. Captured once in my-id.ca — stored in Canada, with AI on its own servers — every form starts mostly complete.
Frequently asked questions
- Who signs the declaration?
- The affiliating physician and ICHSC operator — confirm signature blocks on ontario.ca.
- How does my-id.ca help?
- It autofills physician CPSO numbers and ICHSC licensee details across community surgical centre forms.
- Is this the same as ICHSC expansion?
- Expansion uses ON00878; affiliation authorization is a separate physician credentialing step.
Fill it once. Reuse it everywhere.
Save your information in my-id.ca once, then autofill this form and the next one — web forms with the Chrome extension, PDFs right in the app. Your data is stored in Canada and AI runs on my-id.ca's own servers, never sent to third-party AI providers.