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

Assistive Devices Program (ADP)
5700 Yonge Street, 7^th 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!

• You may choose to take advantage of a popular method of receiving your payment: Direct Deposit.
• With Direct Deposit, The Government of Ontario will deposit your payment directly into your bank account.  The Government does not charge for this service.
• If you do not wish Direct Deposit, a cheque will be mailed to you.

Advantages of Direct Deposit:

• Your deposit will always be on time. 
• There is no risk of your payment being lost, stolen or damaged.
• In the event of illness, or if you are travelling or on vacation, your payment will be safely and automatically deposited.
• We assure complete confidentiality.

Confidential when completed

Section 1 – Client Information

Last Name
First Name
Middle Initial

Address

Health Number Health Number Version
Date of Birth (yyyy/mm/dd)
Home Telephone (include area code)

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: www.health.gov.on.ca.  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.

Signature of Client
    Date (yyyy/mm/dd)

Section 3 – Check List

Check one only
to Start Direct Deposit
to Change Information on Direct Deposit
To Stop Direct Deposit (Note:  complete Sections 1 and 2 only)

• If blank cheque is enclosed with VOID written across it, complete boxes 1-4 (do not sign on void cheque).
• If blank cheque not enclosed, complete sections 1-9 and have your Financial Institution complete sections 5-9 to confirm information.

Direct Deposit Routing Number

4. Name(s) of account holder(s)

5. Financial Institution Name

Address

6.  Financial Institution Official – First name, Last name


7. Confirmation/Signature of Financial Institution Official


8. Financial Institution Telephone Number (include area code)
   ext

9. Date (yyyy/mm/dd)

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