Health Technology Assessment Application

Ontario Health conducts health technology assessments that are evidence-based reviews on a variety of important health care services and medical devices. This includes, but is not limited to, medical devices, medical tests, genetic tests, surgical procedures, health care programs, and complex health system interventions, including models of health care delivery. These assessments also include recommendations on what should be publicly funded.

If you would like to submit a topic for a health technology assessment, please complete the following form.

1. Date *This question is required. This question requires a valid date format of MM/DD/YYYY.

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2. GENERAL INFORMATION *This question is required.

Name

Email Address This question requires a valid email address.

Phone Number

4. If Other, please provide details

4. Affiliated health care facility, if applicable (e.g., hospital, regional authority)

5. If Other, please note source

DESCRIPTION OF HEALTH TECHNOLOGY

5. Name of health technology

6. Why do you want a health technology assessment completed for this technology?

7. What health condition does the health technology treat?

8. If you have other information that is important for us to know, please include it here. This may include the age of the population, the stage or severity of the disease, or anything else you feel is relevant to this health technology.

9. What is the current treatment for the health condition?

10. Is this technology licensed by Health Canada?

11. Is this technology being used in Ontario?

12. What is the cost of the technology?

14. You have indicated that this technology is publicly funded. Please provide additional details.

14. You have indicated that the technology is not publicly funded. How is this technology currently being accessed?

14. Is this technology being used in other Canadian provinces and/or other countries?

15. You have indicated that the technology is being used in other Canadian provinces and/or countries. Where is the technology being used?

EVIDENCE SOURCES

15. Has Ontario Health previously reviewed and made a funding recommendation about this health technology? Please check Reports and Recommendations for previous evidence reviews.

16. If Ontario Health has previously reviewed this technology, please tell us why a re-assessment of this health technology would be important.

16. Do you know if another health technology assessment agency has reviewed this technology (e.g. Canadian Agency for Drugs and Technologies in Health, National Institute for Health and Clinical Excellence, etc)?

17. Please list the agencies that have reviewed this technology.

ADDITIONAL MATERIALS

17. If you have relevant information concerning the benefit of the technology, equipment, technique, or treatment strategy, please include it with your application.
This evidence may include, for example, published research or economic evaluations, patient or doctor experience/interviews, and/or manufacturer information. To include a hyperlink as part of your submission, paste it into a Word document and upload the document. Please do not submit personal health files.

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18. I acknowledge that a quotation or summary of my information may be included in some of Ontario Health documents that are available to the public. However, my name will never be included in these published documents. *This question is required.

I consent to make my information available to the public.

If you have any concerns regarding the collection or management of your personal information, please consult our privacy policy. For any additional questions, please contact our Chief Privacy Officer by emailing info@ontariohealth.ca.