Part A: To be completed by Applicant (or authorized third party representative)
The applicant completes Section 1 (new, renewal, change of information, replacement or returned permit, with any current or previous permit number) and Section 2 (name, date of birth, contact details, addresses, and whether they will be a passenger or a passenger/driver, with an Ontario driver's licence number). They sign a declaration and authorize the release of health information to ServiceOntario. A parent or legal guardian signs for a child under 18; an authorized representative must provide evidence.
Part B: To be completed by a Regulated Healthcare Practitioner
Enter the applicant's last and first name at the top of Part B, then complete Sections 1, 2 and 3. Health documents filed with the application are privileged under the confidentiality provisions of the Freedom of Information and Protection of Privacy Act. Part B isn't required for permanent renewals, changes of information or replacements, except that a permanent permit expired for more than a year needs new certification.
Section 1: Assessment of Health Conditions
Certify one or more of seven conditions: (A) cannot walk without another person's help or a brace, cane, crutch, lower limb prosthesis or similar device, or needs a wheelchair; (B) lung disease with forced expiratory volume in one second under 1 litre; (C) portable oxygen is a medical necessity; (D) cardiovascular disease with functional capacity Class III or IV; (E) walking severely limited by an arthritic, neurological, musculoskeletal or orthopaedic condition; (F) visual acuity 20/200 or poorer in the better eye with correction, or a field of vision with both eyes of 20 degrees or less in diameter; (G) mobility severely limited by other conditions or functional impairments.
Section 2: Status of Condition (select 1 only)
Choose one status. Permanent: the condition is not expected to improve with time, and the permit renews every 5 years without re-certification. Subject-to-change: a health assessment is required every five years, so each renewal needs a new Part B. Temporary: enter the estimated length of the condition in months, to a maximum of 12; renewal also needs new certification.
Section 3: Regulated Healthcare Practitioner Information
Enter your full name, college number, telephone number and fax number, and tick the college you are registered with: Physicians and Surgeons, Occupational Therapists, Physiotherapists, Chiropractors, Nurses (Nurse Practitioner, extended class) or Chiropodists of Ontario. Print or stamp your name and address in the box provided. The applicant's consent in Part A allows ServiceOntario to verify the application with health practitioners.
Declaration
Sign and date (yyyy/mm/dd) to certify that the applicant meets the eligibility requirements, that your information is true and complete, and that you are not treating yourself or family members. False statements are referred to law enforcement under the Criminal Code and Highway Traffic Act and to your college for investigation of professional misconduct. The application remains valid for up to 6 months from your signature date.