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Ontario Special Diet Allowance Form (3111/3112)

Ontario Works and ODSP use the Application for Special Diet Allowance (3111 English, 3112 French) to confirm that a recipient has a medical condition on the Special Diets Schedule. The health professional lists the qualifying conditions and, for most conditions, a diet period of 6 months, 12 months or indefinite, and the applicant signs the consent. The allowance helps with diet costs above those of a normal diet.

Who completes it

A physician registered with the CPSO, a registered nurse in the extended class, a registered dietitian, a registered midwife or a traditional Aboriginal midwife completes the health professional sections. Midwives may only confirm inadequate lactation or contraindicated breast-feeding, and the applicant signs the Section 4 declaration and consent.

Submitting and payment

How to submit it
The applicant returns the original form to the local Ontario Works or ODSP office; photocopies, faxed copies and altered forms are not accepted.
Who pays
For physicians the fee is covered under OHIP with the billing code printed at the top of the form, while RN(EC)s, dietitians and midwives invoice the local office with the recipient's name, member ID and their college registration number.

Good to know

  • A form is incomplete if Section 2's number of conditions does not match Section 3, the professional has not signed, or each eligible condition is not indicated and initialled.
  • For 6- or 12-month allowances, the review starts 90 days before the review date, and the recipient receives a Notification of Review letter with a new application.
  • Only the original ministry-approved form is valid, and offices issue an original form for each benefit unit member who requests one.
  • A refusal comes with an appealable decision letter; an internal review must be requested before any appeal to the Social Benefits Tribunal.

Get the official form

Download the current version from the source each time; forms change without notice.

Application for Special Diet Allowance

Official page

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.

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Frequently asked questions

Who can complete Ontario's Special Diet Allowance form?

A physician registered with the College of Physicians and Surgeons of Ontario, a registered nurse in the extended class, a registered dietitian, a registered midwife, or a traditional Aboriginal midwife recognized by their community. Midwives can only confirm a diet need for inadequate lactation or when breast-feeding is contraindicated.

Can the Special Diet Allowance form be faxed or photocopied?

No. The Ontario Works directive says photocopies, faxed copies and altered forms may not be issued or accepted, and a photocopy of a completed form is treated as incomplete. The applicant must return the original ministry-approved form to the local office.

Which conditions qualify for the Special Diet Allowance?

The Special Diets Schedule includes unintended weight loss from conditions such as cancer, HIV or Crohn's disease, celiac disease, chronic wounds or burns, diabetes, hypertension, dysphagia needing thickened fluids, milk allergy or lactose intolerance, and renal failure. Where some listed conditions overlap, only the highest allowance applies.