Government of Ontario: Ministry of Health and Long-Term Care

Assistive Devices Program (ADP)
5700 Yonge Street, 7th Floor
Toronto ON  M2M 4K5

Tel:          416 327-8804
                1 800 268-6021
TTY:        416 327-4282
TTY:        1 800 387-5559

Application for Direct Bank Payment

Direct Deposit :  It’s your choice!

Advantages of Direct Deposit:

Confidential when completed

Section 1 – Client Information


The Ministry of Health and Long-Term Care’s (the Ministry) collection of the personal health information on this form is necessary for the purposes of assessing and verifying eligibility for the Assistive Devices Program, and for all other purposes related to the proper administration of that Program.

This information may be used or disclosed in accordance with the Personal Health Information Protection Act 2004, as set out in the Ministry’s “Statement of Information Practices” which is accessible at:  Applicants may withhold their consent to the collection of this information; however, doing so will interfere with their coverage under the Assistive Devices Program.  For more information on the Ministry’s Information Practices, or the collection of the personal health information on this form, call 1 800 268-6021 or 416 327-8804 or write to the Program Manager, 5700 Yonge Street, 7th Floor, Toronto ON  M2M 4K5.

Section 2 – Client Signature

I, as the person entitled to receive a payment from the Assistive Devices Program, hereby authorize the Government of Ontario to deposit, until further notice, the payment into my account by means of direct deposit and therefore consent to provide my personal banking information to facilitate this process.


Section 3 – Check List

Check one only

Direct Deposit Routing Number



Please mail completed form to:
Ministry of Health and Long-Term Care
ADP Payment Unit
P.O. Box 48
Kingston ON  K7L 5J3