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

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

Application for Rehabilitation
Assessor/Fitter/Dispenser Status

Section 1 – Mailing Address

PLEASE PRINT

Last Name
First Name
Middle Initial

Address

Building Number
Street Name
Suite/Apt Number
Lot/Concession/Rural Route
City/Town
ON
Postal Code

Business Telephone (include area code)
Fax number (include area code)
Email Address

Section 2 - Details

Device category for which you are applying.

Note: A separate application is required for each category.
(Refer to Attachment A for sub-categories)

Conventional Limb Prostheses (Rehabilitation Assessor)
Externally Powered Upper Limb Prostheses (Rehabilitation Assessor)
Hearing Aids (Dispenser)
Orthotics (Rehabilitation Assessor)
Pressure Modification Devices - Hypertrophic Scar Management (Certified Fitter / Manufacturer Representative)
Pressure Modification Devices - Lymphedema Management (Certified Fitter / Manufacturer Representative)

If you are currently a registered authorizer, fitter, rehabilitation assessor or dispenser with the ADP, specify your authorizer number

Indicate your profession

Audiologist
Certified Fitter
Hearing Instrument Specialist
Hearing Instrument Dispenser
Occupational Therapist
Physiotherapist

Workshop Information

Workshop
Date (yyyy/mm/dd)
Location
Date Received (yyyy/mm/dd)
Approval Date (yyyy/mm/dd)
Permanent Number

Section 3 - Experience

Specify and briefly describe other relevant formal or informal educational programs, workshops, manufacturer’s training programs, conferences completed/attended in the past 5 years.

Describe your experience in prescribing/assessing/fitting the device for which you are seeking ADP fitter/dispenser status.

Section 4 - Employment Locations (hearing aid dispensers must provide ADP registered vendor address)

Location 1

Employer’s Name

Is this your preferred mailing address

Yes No (Default to Mailing Address in Section 1)

Address

Building Number
Street Name
Suite/Apt Number
Lot/Concession/Rural Route
City/Town
ON
Postal Code

Business Telephone (include area code)
Fax number (include area code)
Email Address

Location 2

Employer’s Name

Address

Building Number
Street Name
Suite/Apt Number
Lot/Concession/Rural Route
City/Town
ON
Postal Code

Business Telephone (include area code)
Fax number (include area code)
Email Address

Location 3

Employer’s Name

Address

Building Number
Street Name
Suite/Apt Number
Lot/Concession/Rural Route
City/Town
ON
Postal Code

Business Telephone (include area code)
Fax number (include area code)
Email Address

Use Attachment B for additional locations

Section 5 - Confirmation

The information provided on this form is true, correct and complete to the best of my knowledge. I understand that I will have to sign and comply with the terms specified in the Authorizer Agreement and the Conflict of Interest Protocol.

Signature

Date (yyyy/mm/dd)

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

Application for Rehabilitation Assessor/Fitter/Dispenser Status

Section 1 – Mailing Address

Section 2 - Details

Workshop Information

Section 3 - Experience

Section 4 - Employment Locations (hearing aid dispensers must provide ADP registered vendor address)

Section 5 - Confirmation

Application for Rehabilitation
Assessor/Fitter/Dispenser Status