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Forms and Applications : Assistive Devices

Forms are listed alphabetically in Portable Document Format (PDF). To view and print the forms, you need to have Adobe Acrobat® Reader installed on your computer. You can download this free software from the Adobe Web site.

Click on the form title to open the form. You can fill-in the form on your screen and print it, or use the disk icon on the Reader toolbar to save a blank copy of the form to your computer. Filled-in forms cannot be saved.

To print, use the printer icon on the Reader toolbar. For form sizes larger than 8.5 x 11 inches, check the Fit to Page box in the print menu window. See the Forms and Applications main menu page for detailed instructions.

1429-67 Insulin Syringes for Seniors Program VIEW ONLY
1945-67 Ostomy Grant Applicant Information VIEW & PRINT
1976-67 EA Equipment/Supply Authorization VIEW ONLY
2045-67 Release of Information FILL & PRINT
2196-67 Application for Funding Mobility Devices  FILL & PRINT
2451-67 Home Oxygen Program VIEW ONLY
2961-67 Request for Special Approval - Orthotics and Prosthetics FILL & PRINT
3183-67 Application for Limb Prosthesis Funding Assistance VIEW ONLY
3224-67 Hearing Device Application VIEW ONLY
3414-67 Hearing Aid Dispenser Application FILL & PRINT
4392-67E Breast Prosthesis Grant Application/Information  FILL & PRINT
4446-67E Application for Funding Insulin Pumps and Supplies for Children FILL & PRINT

For more information
Call the ministry INFOline at 1-866-532-3161
(Toll-free in Ontario only)
TTY 1-800-387-5559
Hours of operation : 8:30am - 5:00pm
  
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