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Ontario ADP Mobility Devices Application (2196-67E)

Ontario's Assistive Devices Program uses this application to fund wheeled walkers, forearm crutches, manual and power wheelchairs, scooters, paediatric standing frames and wheelchair seating for people with a long-term physical disability needing the device for six months or longer. An occupational therapist or physiotherapist registered as an ADP authorizer assesses functional mobility and completes the form. ADP pays 75% of the approved price.

Who completes it

The ADP-registered authorizer, an occupational therapist or physiotherapist, completes Section 2, including the presenting medical condition and functional mobility status, and signs Section 4. There is no physician or nurse practitioner section; the applicant or agent signs Section 3 and the proof of delivery, and the vendor signs.

Submitting and payment

How to submit it
Submit to ADP once the applicant or agent, authorizer and vendor have signed, including only the listed attachments, such as vendor quotes or the dynamic positioning justification chart. ADP aims to review a properly completed form within eight weeks.

Good to know

  • Power wheelchairs with power dynamic tilt or recline must come from the Central Equipment Pool for High Technology Wheelchairs and need the Justification for Funding Chart (5023-67E).
  • ADP excludes devices for occasional use, alternate transportation, school or work only, exercise programs, or social and recreational purposes, and doesn't fund power wheelchair batteries.
  • ADP doesn't set or pay authorizer assessment fees, so whether the applicant pays for the assessment depends on the authorizer and their employer.
  • If ADP finds an applicant ineligible, they can appeal in writing with their health card number, the decision appealed, the reasons and any supporting documentation.

Get the official form

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

Application for Funding Mobility Devices

Demande de financement pour aides à la mobilité

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Fill it with Vero

Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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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

Does a physician need to sign the ADP mobility devices application?

Form 2196-67E has no physician or nurse practitioner section. The ADP-registered occupational therapist or physiotherapist authorizer assesses functional mobility, records the presenting medical condition, selects the device and signs. The applicant or agent and the vendor also sign before the form goes to ADP.

How much does ADP pay for a wheelchair or walker?

ADP pays 75% of the approved price and the applicant pays 25%, or ADP pays 100% for people on Ontario Works, ODSP or ACSD. Non-funded options, power wheelchair batteries and repairs, except for Central Equipment Pool equipment, are the applicant's cost.

What happens if mobility equipment is ordered before ADP approval?

ADP pays only the amount it approves, after the approval date. If the vendor orders equipment before approval and ADP then refuses funding, the applicant must pay the vendor the full amount. The applicant chooses a vendor at the time of the authorizer's assessment.