he purpose of this form is to collect necessary information to obtain authorized consent and assure identity, under the Freedom of Information and Protection of Privacy Act (FIPPA), for application of services delivered by the Ministry of Health on your behalf (or for a “Health Care Group” in which you are a registered member), including:
• Application for an OHIP Billing Number
• Changes to Health Care Group Registration Information
Used by Canadian board -certified orthotists registered with ADP to request funding for custom -made orthoses
Used to apply for Funding for Visual Aids
Used to apply for Funding for Pressure Modification Devices
Application for Funding Mobility Devices
Used to apply for Funding for Communication Aids
For Specialist physician & ADP registered authorizers to request funding for extraoral (facial) prostheses.
For Specialist physician & ADP registered authorizer to request funding for intraoral (mouth) prostheses.
Used to apply for Funding for Respiratory Equipment & Supplies
Used by clients to apply for funding for a silicone breast prosthesis(es)
Used by Amputee Team, registered with ADP to request funding for conventional upper/lower limb prosthees.
Application used by Homemaker and Nurses to request reimbursement from the Province for services provided.
For retailers that primarily sell specialty tobacco products to apply for a tobacconist registration.
Used to request a change in vendor for an approved Assistive Devices Program claim
Used to renew funding for rtCGM
Used to renew funding for home oxygen therapy.
