Form completed by clients to record their wishes for organ/tissue donation

Used to renew funding for rtCGM

Used to apply for Funding for Communication Aids

Used to apply for Funding for Visual Aids

Used to apply for Funding for Pressure Modification Devices

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 by Canadian board -certified orthotists registered with ADP to request funding for custom -made orthoses

Used to apply for Funding for Ocular Prostheses

Application used to determine elegibility for funding by ADP for insulin pumps and supplies

Used by Amputee Team, registered with ADP to request funding for conventional upper/lower limb prosthees.

Used by clients to request funding assistance for Insulin Pumps and Supplies for Children

Transfer of ownership of Integrated Community Health Services Centre (ICHSC) licence.

Licensees of Integrated Community Health Services Centres (ICHSCs) must submit an application and obtain written approval from the Director of Integrated Community Health Services Centres prior to a centre’s relocation. For the purposes of this application, a “Fixed Site” centre is a licensed ICHSC where the Limitations and Conditions of the licence specify a single geographic location or address where specified services may be provided.

The form is used to confirm a physician's qualifications to provide the requested services prior to processing a request to affiliate to a particular ICHSC. The licensee must ensure that the physician has been affiliated to the centre before they begin to provide licensed services.

The ICHSC Program must be notified of a change in quality assurance advisor through the submission of the Quality Assurance Advisor form which must be signed by both the centre’s quality assurance advisor and the licensee.

This form is to be used by Public Health Units after dental screening to notify parents/guardians that their child would benefit from preventive dental services. If the parent/guardian can complete the form and return it to the Public Health Unit if they wish to enroll their child into the Preventive Services Only Stream of Healthy Smiles Ontario.

Form authorizes the ministry to disclose an individual's personal claims history information directly to a third party.

Used to renew funding for home oxygen therapy.

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.