Forms clinicians complete so patients can get funded devices, prior-approved treatment, medical travel help and home or long-term care, from Ontario's ADP to RAMQ.
Provincial programs fund devices, out-of-province treatment, medical travel and home care, and their forms need a clinician's input. Ontario's Assistive Devices Program (ADP) has the longest list, including Mobility Devices (2196-67E), Home Oxygen Therapy (2451-67E) and Respiratory Equipment (4793-67E). OHIP uses prior approval forms such as the out-of-country request (ON00314E), and RAMQ has its own device forms, such as the prescription for orthoses, prostheses and mobility aids (form 3497).
Most ADP and OHIP forms are XFA e-forms that open and fill correctly only in Adobe Acrobat or Reader. ADP applications go in once the applicant, the authorizer or prescriber and the vendor have all signed. RAMQ's forms are in French only. Travel and home care forms vary: BC's Travel Assistance Program form (HLTH 2900) is pre-printed and ordered from HIBC, while Ontario Health atHome uses 14 regional referral forms. Saskatchewan and New Brunswick run their own insulin pump programs.
Formulaire de demande d'accès spécial aux instruments médicaux
A health care professional applies for access to a medical device that is not licensed in Canada, for a patient, under the Medical Devices Special Access Program.
Document médical autorisant la consommation de cannabis à des fins médicales
The health care practitioner's medical document supporting a patient's use of cannabis for medical purposes, so the patient can buy from a federally licensed seller or register with Health Canada for personal or designated production.
Used by enrolled NIHB mental health counselling providers for prior approval, exception requests for more hours, approval after services were given, and claims.
Application for the At Home Program (medical benefits/respite) for children with severe disabilities or complex health needs who depend on others for at least 3 of 4 daily living activities.
Requests At Home Program funding for extended OT, PT, speech-language pathology, chiropractic and massage services for enrolled children aged 5 and over.
Request for At Home Program funding of medical and incontinence supplies for an enrolled child, with clinical justification.
Requests At Home Program funding for prescription lenses and frames needed because of an enrolled child's disability or specific medical diagnosis.
Prior approval request for MSP funding of elective (non-laboratory) medical treatment outside Canada that is not available in Canada.
HLTH 2900Travel Assistance Program (TAP BC) form issued at referral so an MSP patient can get discounted travel to MSP-insured specialist services not available locally.
Application for AHCIP funding of insured health services that are not available in Canada.
Prior-approval request for travel assistance when a child must go out of province for a medically required treatment not available in Saskatchewan.
Application for insulin pump coverage under SAIL's Saskatchewan Insulin Pump Program (type 1 diabetes). For adults.
Application for insulin pump coverage under SAIL's Saskatchewan Insulin Pump Program (type 1 diabetes). For patients under 18.
Application for SAIL's Therapeutic Nutritional Products Program (income-tested help with prescribed nutrition products).
Referral of a patient to Ontario Health atHome for home and community care services.
Toronto Central region referral for home and community care services.
Réclamation hors province pour services médicaux
Claim for reimbursement by OHIP of physician services received by an Ontario resident elsewhere in Canada when not billed through reciprocal billing.
Demande d'approbation de reglement de frais d'actes chirurgicaux proposees
Surgeon asks OHIP to approve payment before performing an in-province surgical procedure that needs prior approval.
Demande de subvention pour stomisés
ADP grant toward ostomy supplies for a person with a permanent ostomy.
Demande de financement pour aides à la mobilité
ADP funding for manual/power wheelchairs, scooters, positioning devices and ambulation aids (walkers, etc.).
Demande de financement de l’oxygénothérapie à domicile
ADP funding for home oxygen (short-term, long-term for resting/exertional hypoxemia, palliative).
Demande d'approbation du règlement d'honoraires pour actes bucco-dentaires proposés
Dentist asks OHIP to approve dental/oral surgery procedures to be done in hospital and covered by OHIP.
Demande d'exemption médicale - Carte Santé
Requests that no photo appear on the photo health card for medical reasons.
Demande de financement pour membre artificiel
ADP funding for artificial limbs and components.
Demande de financement pour appareils auditifs
ADP funding for hearing aids, FM systems, cochlear implant/BAHA processors and TTYs.
Demande de règlement d'un fournisseur de soins de santé - Programme de diagnostic et de traitement pour les personnes non assurée
Physician/provider claim for payment for tuberculosis diagnosis and treatment services given to uninsured persons (TB-UP program).
Demande d'examen complet de la vue
Physician or NP recommendation that lets a patient with a medical condition affecting the eye get an OHIP-insured major eye exam from a physician once every 12 months.
Standard Ontario requisition for community laboratory tests ordered by a physician or other authorized practitioner.
Demande de financement pour pompes à insuline et fournitures pour enfants
ADP funding for an insulin pump and supplies for a child with diabetes.
Demande d'approbation préalable du remboursement de services de santé hors pays/hors province assurés – Analyses de laboratoire et génétiques
Prior approval for OHIP to pay for lab or genetic tests performed outside Ontario that are not available in Ontario.
Demande de financement pour pompes à insuline et fournitures pour adultes
ADP funding for an insulin pump and supplies for an adult with diabetes.
Demande de financement Prothèses oculaires
ADP funding for an artificial eye.
Évaluation de l’état de santé – Santé à domicile Ontario
Medical health assessment required to decide whether an applicant is eligible for long-term care home admission.
Demande de financement Pompe et matériel d'alimentation entérale
ADP funding for an enteral feeding pump and supplies.
Demande de financement Équipement et matériel pour ventilateur
ADP funding for ventilator equipment and supplies.
Demande de financement Équipement et fournitures respiratoires
ADP funding for respiratory equipment and supplies (e.g., positive airway pressure devices for sleep apnea).
Demande de financement Orthèses
ADP funding for custom orthoses (braces) for long-term physical disability.
Demande de financement Prothèses maxillo-faciales intra-buccales
ADP funding for intraoral maxillofacial prostheses.
Demande de financement Prothèses maxillo-faciales extra-buccales
ADP funding for extraoral facial prostheses.
Demande de financement Dispositifs de modification de la tension
ADP funding for pressure modification devices.
Demande de financement Aides visuelles
ADP funding for visual aids for people with low vision.
Demande de financement Aides à la communication
ADP funding for communication aids.
Présentation d'une demande au Programme de réhabilitation orale et maxillo-faciale (PROM)
Refers an adult (18+) with a valid Ontario health card for assessment by the Oral and Maxillofacial Rehabilitation Program (prostheses funded through ADP).
Demande d'approbation préalable du remboursement de services de santé hors province assurés (autre province ou territoire)
Prior approval for OHIP to fully pay for insured hospital/physician services in another Canadian province or territory not covered by reciprocal billing.
Dispositifs de positionnement dynamique électriques - Tableau justificatif pour financement
Authorizer justification attached to a mobility-device application when power dynamic positioning devices are requested.
Renouvellement du financement de l'oxygénothérapie à domicile
Renews ADP home oxygen funding at the end of an approved funding period.
Demande d'approbation préalable du remboursement d'un changement chirurgical de sexe
Prior approval for OHIP-insured gender-affirming (sex-reassignment) surgery in Ontario, elsewhere in Canada, or out of country.
Addendum to the ventilator application capturing primary and secondary diagnoses.
Demande d’approbation préalable du remboursement de services de santé hors pays assurés
Ontario physician asks OHIP to pre-approve full payment for medically necessary treatment outside Canada that is unavailable, or medically delayed, in Ontario.
Demande d'aide financière pour surveillance du glucose en continu (SGC) en temps réel
ADP funding for a real-time continuous glucose monitor for eligible people with diabetes.
ON00509EFormulaire d’aiguillage pour patients hospitalisés
Refers a child/youth to CPRI inpatient services.
ON00510EFormulaire d’aiguillage pour patients en consultation externe
Refers a child/youth to CPRI outpatient services.
Aiguillage vers un service de consultation médicale tertiaire
Refers a child/youth for a one-time developmental-behavioural paediatric or child and adolescent psychiatry consultation (including ASD diagnostic opinion) at CPRI.
Recommendation – Assistive Listening Device
Audiologist recommends assistive listening/alerting devices (text transmission, sound transmission, environmental alerting) for an eligible person under RAMQ's hearing aids program.
Medical Certificate – Hearing Aids Program
Otolaryngologist certifies the type of hearing loss in each ear, whether it is permanent, any contraindications, and the need for a hearing aid or assistive listening device under RAMQ's hearing aids program.
Medical Prescription – Orthoses, Prostheses, Mobility Aids, Posture Aids
Prescription for devices covered by RAMQ's program for devices that compensate for a physical deficiency (orthoses, prostheses, orthopedic devices, mobility and posture aids): diagnosis, incapacity and medically required duration.
Certification of Need for a Mobility or Posture Aid
Functional evaluation and justification for a manual or power wheelchair, positioning base, stroller or posture aid (initial, additional or replacement) supplied through a rehabilitation establishment's technical-aids service.
Medical Certificate for Exemption from Photo or Signature – Health Insurance Card
Physician certifies that an illness or impairment prevents the insured person from having a photo taken and/or signing, so the Québec health insurance card can be issued without them.
Request for Authorization – Plastic Surgery
Surgeon's request for RAMQ authorization so plastic surgery (e.g. scar correction, breast surgery, lipectomy) is covered as an insured service.
Request for Prior Authorization to Obtain Medical Services Outside Québec
Physicians ask RAMQ to authorize in advance the coverage of medical (and hospital) services a patient will receive outside Québec (regulation under the Health Insurance Act, ss. 23.1–23.2; Hospital Insurance Act regulation, s. 15).
Confirmation de l'admissibilité médicale à la couverture des capteurs de glucose
Confirms medical eligibility for continuous glucose monitoring (CGM) sensor coverage under NBIPP.
Confirmation d'admissibilité médicale à la couverture de pompes et fournitures
Confirms a client's medical eligibility for insulin pump and/or pump supplies coverage under the New Brunswick Insulin Pump Program (NBIPP).
Demande d'approbation préalable - Assurance-maladie
Physician asks Medicare to decide before treatment whether a proposed, possibly cosmetic, service is insured: service code, units, diagnosis, deformity and functional impairment.
Pre-approval request for insured gender-affirming surgery, including surgery referred out of province.
Physician or NP report of active diagnoses and medical status for a medically stable patient applying for admission to a long-term care facility.
Standard client needs assessment for long-term care and community support services (e.g. home support subsidy).
Physician letter, on physician or hospital letterhead, stating why a patient needs a non-medical escort to reach a specialized medical service. MTAP needs it to cover escort travel.
Referral for admission to a Yukon long-term care home or the community day program.
Referral from the patient's health-care team for hospice admission in a Yukon continuing care facility.
Requests a consultation with the Yukon Palliative Care Resource Team for someone with a life-limiting illness.
Provider referral to Yukon Healthy Living programs: Your Health! Your Way!, Diabetes Wellness Series, supervised exercise and Pulmonary Rehabilitation.
Extended Health Benefits claim with a Record of Appointment(s) that the attending clinician signs to confirm medical appointments, e.g. for EHB-supported medical travel.
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
It depends on the device. Mobility devices need an ADP-registered authorizer. Home oxygen needs a physician or NP, plus testing by a respiratory therapist or other regulated health professional. Insulin pumps need a physician or NP with an ADP-registered diabetes education program, and CPAP and other respiratory equipment need a physician or NP and the sleep lab diagnosis. Each application goes to ADP once the applicant, authorizer or prescriber and vendor have signed.
Most are XFA-based e-forms, which open and fill correctly only in Adobe Acrobat or Reader; browsers and most PDF libraries cannot render the fields. This applies to every ADP application and to OHIP forms such as the out-of-country prior approval (ON00314E), the proposed surgery approval (0691-84E) and the major eye exam request (4347-84E). Save the file and open it in Adobe Reader instead.
A practising Ontario physician submits the Request for Prior Approval for Full Payment of Insured Out-of-Country (OOC) Health Services (ON00314E) with medical documentation, and approval must come before treatment. The form is designed to be completed and submitted electronically. Care in another province that reciprocal billing does not cover uses form 4963-84E, and out-of-country or out-of-province lab and genetic tests use 4521-84E.
Form 3497, the Ordonnance médicale (medical prescription) for orthoses, prostheses, mobility aids and posture aids, records the diagnosis, incapacity and medically required duration under RAMQ's devices program. RAMQ says a prescription is needed only in some situations, such as a first mobility aid. For wheelchairs and posture aids from a rehabilitation establishment, an OT or physiotherapist completes form 3841 and the prescribing physician signs.