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Ontario ADP Home Oxygen Application (2451-67E)

Ontario's Assistive Devices Program uses this application to fund rental of a basic home oxygen system and related services for people with a respiratory condition needing oxygen, under short-term, long-term or palliative programs. The physician or nurse practitioner records diagnoses and oximetry or blood gas results, and an ADP-registered vendor sets up therapy. ADP reviews a properly completed form in about two weeks.

Who completes it

The physician or nurse practitioner, or a registered respiratory therapist in some cases, confirms diagnoses and test results and signs Section 4; a regulated health professional who did the oximetry signs if the prescriber didn't. The vendor selects the funding program and delivery system, and the applicant or agent signs.

Submitting and payment

How to submit it
Once the prescriber, the ADP-registered vendor and the applicant or agent have completed their sections, the form goes to ADP with signed, dated oximetry print-outs. If funding is approved, ADP notifies the vendor; if not, the applicant is told by mail.

Good to know

  • Use this form for first-time funding, after a gap of more than 90 days, or when a prescriber had discontinued therapy; continuing funding uses the renewal form 5037-67E.
  • Signed, dated oximetry print-outs must accompany the form for every program except palliative care. There is also a PaO2 field, with a box if ABGs couldn't be taken due to medical risk.
  • Exertional hypoxemia needs an Independent Exercise Assessment at a hospital or independent health facility, confirmed by a respirologist or internist unless one signs Section 4.
  • ADP pays 100% of basic system rental for people 65 or older, on social assistance, receiving home care professional services, or in long-term care; others get 75%.

Get the official form

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

Application for Funding Home Oxygen Therapy

Demande de financement de l’oxygénothérapie à domicile

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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

Who can sign the ADP home oxygen application?

A physician or nurse practitioner, with their OHIP billing number, certifies that other treatment measures were tried without success and that the prescribed oxygen is medically necessary. A registered respiratory therapist employed by a hospital or in the community, and not by a home oxygen vendor, can sign instead.

What tests does ADP need for home oxygen funding?

Except for palliative care, the form needs oximetry results at rest, on exertion or during sleep, with signed and dated print-outs attached. It also records arterial blood gas PaO2, with a box to tick if ABGs couldn't be taken because of medical risk. If the prescriber didn't perform the oximetry personally, the regulated health professional who did must sign.

Which home oxygen funding programs does ADP offer?

The vendor selects one: short-term oxygen therapy, long-term therapy for resting hypoxemia, long-term therapy for children, long-term therapy for exertional hypoxemia, or palliative care. Short-term therapy applies when oxygen is needed for discharge from hospital or the emergency department, or to avoid an emergency visit from a long-term care home.