OLSP

Ontario Lung Screening Program (OLSP)

This is a draft standardized eReferral form for the OLSP. Final design may differ.
Please provide your feedback in the form on the right-hand side

The form is designed to be viewed on a computer.

For more information about specific sections on the form, please click the yellow "Notes" buttons on the left hand side of the page.

Patient Information

Surname:

First:

DOB:

Gender:

Male

Female

Other

HN:

Mobile #:

Home #:

Business #:

Email:

Address:

* Indicates a required field

[Optional] Additional Patient Information

Preferred Name:

Sex assigned at birth:

Female

Male

Intersex

Unknown

Pronouns:

She/Her

He/Him

They/Them

Other

Preferred language:

English

French

Other

Best method of contact:

Mobile

Home

Business

Email

Identify parent/guardian, care contact, or Substitute Decision Maker

First Contact Name: *

Phone (if different than pt):

Email (if different than pt):

Relationship (incl. SDM):

Is this person an appointment booking contact?*

Yes

No

Second Contact Name:

Phone (if different than pt):

Email (if different than pt):

Relationship (incl. SDM):

Is this person an appointment booking contact?

Yes

No

Do not contact (e.g. safety, privacy)

Accessibility concerns or disability

Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, requires escort, current location)

Not everyone who meets the referral criteria will be eligible for lung cancer screening. Following referral, a risk assessment will determine eligibility to participate in the OLSP.

See Frequently Asked Question [Placeholder Link TBD]

Exclusion Criteria

Patients are ineligible for the OLSP if they have:

been diagnosed with lung cancer
ongoing surveillance for lung nodules
hemoptysis of unknown cause
unexplained weight loss ≥ 5 kg (11 lbs) in the past year
ongoing diagnostic assessment, treatment or surveillance for life-threatening conditions (e.g. a cancer with a poor prognosis)

None of the above exclusion criteria apply*

Eligibility Criteria

Patients must meet all conditions under either criteria 1 OR 2 to be eligible for referral to the OLSP.

Select the criteria set where the patient meets all conditions:*

Criteria 1 (Risk Assessment Required):

Age ≥ 55 years
Being referred for the first time or was previously determined to be ineligible for the OLSP
≥ 20 years history of daily tobacco smoking of any amount (including cigarettes, cigars, loose tobacco, pipes or bidi/beedi)
Has OHIP coverage

Criteria 2 (Risk Assessment Not Required):

Age ≥ 80 years
Previously enrolled in OLSP and wants to continue screening
Has discussed continuing lung screening with you
Is well enough to undergo and recover from lung cancer treatment
Has a life expectancy ≥ 5 years to benefit from treatment
Has OHIP coverage

Patient History

Previous Diagnosis of COPD?

Yes

No

Unknown

Additional Relevant Information (if applicable):

Primary Care Clinician

Please Note: The patient’s primary care clinician will be copied on all communications related to their lung cancer screening activity. However, you are asked to notify the patient’s primary care clinician of this referral.

Referrer is not the patient's Primary Care Clinician (e.g. locum or specialist physician)

Specify role:*

Patient has a Primary Care Clinician?*

Yes

No

Unknown

Primary Care Clinician Name:

Telephone Number:

Fax Number:

I have a time-limited relationship with this patient.

Authorization Signature

If the patient is eligible for screening based on a risk assessment and you sign this form as the referring health care clinician, you:

authorize the use of low-dose computed tomography (LDCT) for the patient’s baseline scan, ongoing routine annual screening and follow-up of nodules, according to OLSP guidance
authorize the patient’s referral for lung diagnostic assessment, if recommended by the reporting radiologist
confirm that you are responsible for ensuring appropriate follow-up of incidental findings

I confirm the above and accept responsibility as the referring health care clinician*

Supporting Documentation

Please attach all relevant diagnostic investigations including previous Chest CT (if done within the last 12 months).

Personal Health Information that is medically relevant has not been disclosed at the request of the patient.

+ Add Attachments

This button is just for demonstration

Referrer's Information

Site Name:

Address:

City:

Province:

Postal Code:

Phone:

Fax:

Billing #:

Professional ID:

Signed:

Role:

Thank you for taking time to review this form.
Ontario Health & Amplify Care

Notes

Overview

This referral form is intended for OLSP sites.
This form was built from the existing OLSP paper form: LungCancerScreening_ReferralForm.pdf
Formatting and style is intended to be consistent across all specialties to reduce cognitive loads
The number of mandatory fields is limited to reduce administrative burdens.

X

Notes

Additional Patient Information

This section is optional for referrers to complete
Referring providers should use their judgement to determine if any of these fields should be completed. Some fields will auto-complete if launched from an integrated EMR or HIS.

X

Notes

Patient Information

These fields are auto-populated when referral is initiated from an integrated Electronic Medical Record (EMR) or Hospital Information System (HIS).

X

Notes

Referrer’s Information

Will automatically populate with the referring provider’s information.

X

OK

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