15 Forms found for assistive devices

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  • 014-0406-67
    Authorizer Agreement with the Assistive Devices Program

    The Ministry of Health and Long-Term Care's Assistive Devices Program provides customer centered support and funding to Ontario residents who have long-term physical disabilities to provide access to personalized assistive devices appropriate for the individual's basic needs. To accomplish this goal the ADP must establish relationships with health professionals in order to ensure that ADP clients are assessed for cost-effective devices that best suit their needs.
  • 014-1565-95
    Assistive Devices Program Confirmation of Payment Instructions

    The form is an application for direct bank deposit for vendors registered with the Assistive Devices Program.
  • 014-3224-67
    Application for Funding Hearing Devices

    Application used to determine eligibility for funding by ADP for Hearing Devices.
  • 014-1903-67
    Statement of Support for Device Listing Wheelchairs, Positioning and Ambulation Aids

    This form is used by manufacturers/distributors of mobility equipment (wheelchairs and wheeled walkers) for the purpose of making application to the Assistive Devices Program requesting approval to list their respective products on the list of approved devices.
  • 014-3437-67
    Application for Funding of Changes/Modifications/New Options to ADP Approved Devices

    This form is used by manufacturers/distributors of mobility equipment (wheelchairs and wheeled walkers) for the purpose of making application to the Assistive Devices Program requesting approval to list their respective products on the list of approved devices.
  • 014-4917-67
    Vendor Registration Application

    The Vendor Registration Application form is an interactive form that will be completed by an Ontario retailer or supplier of assistive devices who is requesting registration with the Assistive Devices Program.
  • 014-5055-67
    Authorizer Registration Change Request

    To maintain registration of health care professionals, termed authorizers, by the Assistive Devices Program
  • 014-1819-67
    Application for Equipment Listing Wheelchairs, Positioning and Ambulation Aids

    This form is used by manufacturers/distributors of mobility equipment (wheelchairs and wheeled walkers) for the purpose of making application to the Assistive Devices Program requesting approval to list their respective products on the list of approved devices.
  • on00383
    English - Request for Change in Vendor

    Used to request a change in vendor for an approved Assistive Devices Program claim
  • 014-1945-67
    Application for Funding Ostomy Grant

    The information on this form is used to determine eligibility for grant assistance under the Assistive Devices Program.
  • 014-4971-67
    Vendor Agreement

    The Ministry of Health and Long-Term Care's Assistive Devices Program provides customer centered support and funding to Ontario residents who have long-term physical disabilities to provide access to personalized assistive devices appropriate for the individual's basic needs. To accomplish this goal the ADP establishes contracts with vendors in order to ensure that ADP funding for clients are in accordance with Program policies.
  • 009-0039
    Expression of Interest

    The Accessibility Innovation Showcase (AIS) is hosted by the Ontario government to demonstrate advances in market-ready assistive technologies and devices, stimulate investment and growth in the industry, and raise the profile of accessibility. The Expression of Interest form should be completed by Ontario-based companies and organizations interested in exhibiting at the event.
  • 014-5050-67
    Vendor Registration Application - Home Oxygen Therapy

    The Vendor Registration Application form is an interactive form that will be completed by an Ontario retailer or supplier of home oxygen therapy who is requesting registration with the Assistive Devices Program.
  • 014-2045-67
    Release of Information About Previous Funding

    Written consent to release information enables the Assistive Devices Program to provide a history of previously funded equipment/supplies to a client and/or third party as specified.
  • on00646
    Ontario Disability Support Program (ODSP) - Mandatory Special Necessities (MSN) Benefit Application

    Application may only be completed for recipients of ODSP. The following approved health care professionals licensed to practice in Ontario can complete the application: • Physicians, Nurse Practitioners, Registered Nurses, Occupational Therapists, Physiotherapists, Physician Assistants, and Psychologists* *Psychologists can only complete the Medical Transportation section of the form. The application may only be completed for medical supplies, items, and devices listed in the MSN Schedule of Benefits (https://www.ontario.ca/page/ontario-disability-support-program-health-and-disability-benefits) and items must not be otherwise reimbursed or subject to reimbursement from any other source.