Referral of a patient to Ontario Health atHome for home and community care services.
- Completed by
- Referring physician, NP or other provider
- Issued by
- Ontario Health atHome
- Format
- Language
- English
Ontario ADP Limb Prostheses Application (3183-67E)
Ontario's Assistive Devices Program uses this application to fund conventional upper and lower limb prostheses and externally powered upper limb prostheses for people missing part or all of an arm or leg. An ADP-registered amputee team, which includes a physician, a prosthetist and a physiotherapist or occupational therapist, assesses the person and completes the form. ADP pays 75% of the approved price.
Who completes it
The amputee team's physician records the diagnosis, amputation type and any surgery, and signs Section 4 certifying a chronic physical disability requiring regular use of the prosthesis. The authorizer selects each item with an application reason, the applicant or agent signs Section 3, and the vendor signs.
Submitting and payment
- How to submit it
- The amputee team submits the completed form to ADP, which aims to review a properly completed application within six weeks and notifies the vendor if funding is approved.
Good to know
- Each item needs a reason code: initial preparatory or definitive device, additional items, modifications, or replacement for growth, atrophy, normal wear or a change in medical condition.
- ADP won't fund prostheses needed only for occasional use, school or work, an exercise program, or social and recreational purposes.
- If equipment is ordered before ADP approves funding and the application is then refused, the applicant must pay the vendor the full amount.
- ADP pays 75% of the approved price, or 100% for people on Ontario Works, ODSP or ACSD. Repairs and maintenance aren't covered.
Get the official form
Download the current version from the source each time; forms change without notice.
Application for Funding Limb Prostheses
Demande de financement pour membre artificiel
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.
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 signs the physician section of the ADP limb prostheses form?
The physician on the ADP-registered amputee team. They give the diagnosis, amputation type and any surgical procedure with its date, and certify after an in-person assessment that the applicant has a chronic physical disability requiring regular use of the prescribed prosthesis, adding their six-digit OHIP billing number.
Does ADP fund powered arm prostheses?
Yes. Externally powered upper limb prostheses, including definitive prostheses, electric hands and elbows, and replacement sockets and components, are covered alongside conventional devices. The authorizer must confirm the applicant needs one as a substitute for a partially or totally absent upper limb.
What warranty comes with an ADP-funded limb prosthesis?
The prosthetist should give the warranty in writing. It covers 6 months against breakage and 3 months for satisfactory fit, provided the person's size or medical condition doesn't change significantly. Component manufacturers may offer their own warranties, and ADP doesn't pay for repairs or maintenance.