Health Assessment – Ontario Health atHome (Fixing Long-Term Care Act, 2021) (Form 4768-69E) Completed Form Examples and Samples
View a detailed, filled-out example of the Health Assessment – Ontario Health atHome (Form 4768-69E). This sample, compliant with the Fixing Long-Term Care Act, 2021, demonstrates how to complete the form to determine eligibility for long-term care services in Ontario.
Health Assessment – Ontario Health atHome (Fixing Long-Term Care Act, 2021) (Form 4768-69E) Example
How this form was filled:
This is an example of a completed Health Assessment (Form 4768-69E) for an elderly individual with complex care needs. The form details the applicant's medical conditions, mobility challenges, and cognitive status to determine their eligibility for long-term care services provided by Ontario Health atHome under the Fixing Long-Term Care Act, 2021.
Information used to fill out the document:
- Applicant Name: Eleanor Vance
- Health Card Number: 1234-567-890-AB
- Date of Birth: May 15, 1941
- Address: 456 Oak Avenue, Ottawa, ON, K1A 0B1
- Substitute Decision-Maker (SDM): Sarah Vance
- Relationship to Applicant: Daughter
- SDM Contact: 613-555-0182
- Assessor Name: Jane Smith, RN
- Assessor's Organization: Home and Community Care Support Services Champlain
- Assessment Date: February 10, 2026
- Primary Diagnoses: Osteoarthritis, Hypertension, Early-stage Alzheimer's Disease
- Mobility Status: Requires walker for all ambulation; identified as a high fall risk.
- Cognitive Status: Mild memory impairment and difficulty with executive functions (e.g., planning, financial management).
- ADL Needs: Requires daily assistance with bathing, dressing, and grooming.
- IADL Needs: Unable to independently manage medications, prepare meals, or use the telephone.
- Services Determined Eligible For: Personal Support (10 hours/week), Registered Nursing (weekly visit), Physiotherapy (bi-weekly).
What this filled form sample shows:
- Applicant and SDM Information: Correctly filled personal details for both the person being assessed and their legal representative.
- Detailed Health Status: Comprehensive documentation of chronic conditions, mobility limitations, and cognitive impairments.
- Functional Needs Assessment: Clear evaluation of Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) requiring support.
- Eligibility Determination: Specifies the exact long-term care services the applicant has been deemed eligible for at home.
- Official and Dated Assessment: Shows completion by a qualified assessor with a current date, as required by the Act.
Form specifications and details:
| Form Name: | Health Assessment – Ontario Health atHome |
| Form Number: | 4768-69E |
| Governing Legislation: | Fixing Long-Term Care Act, 2021 |
| Jurisdiction: | Ontario, Canada |
| Use Case: | Determining eligibility for an elderly person with complex medical and cognitive needs to receive long-term care services at home. |
| Categories: | ACT Health forms, CAR forms, health care forms, health forms, L.A. Care forms |
| Created: | February 12, 2026 07:11 PM |