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ADP Insulin Pump Application for Children (4446-67E)

Ontario's Assistive Devices Program uses this application to pay for an ADP-listed insulin pump and give an annual supplies grant for children with type 1 diabetes. An endocrinologist, specialist physician or nurse practitioner in a program belonging to the Network of Ontario Paediatric Diabetes Programs confirms seven criteria, including pump education. Pump therapy begins with a 90-day trial.

Who completes it

An endocrinologist or other specialist physician or nurse practitioner associated with a paediatric diabetes program in the Network of Ontario Paediatric Diabetes Programs completes Section 2 and signs Section 4, naming the program. The parent or agent signs Section 3 and the proof of delivery, and the vendor completes the pump details.

Submitting and payment

How to submit it
The ADP-registered paediatric diabetes education program helps complete the form, which goes to ADP when the 90-day trial starts; attachments aren't considered. ADP aims to review a properly completed form within six weeks.

Good to know

  • Criteria include glucose checks before each meal and at bedtime, ongoing monitoring of results, insertion site rotation, and no more than one DKA episode in the previous six months.
  • The child must attend the diabetes clinic at least 3 times a year and must have completed an insulin pump education program.
  • ADP pays 100% of the approved pump price to the vendor and an annual supplies grant in quarterly instalments, renewed each year with the diabetes team.
  • If the 90-day trial isn't successful, the pump is returned and the vendor credits ADP in full, so the family can reapply later. Pumps have a 5-year replacement period.

Get the official form

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

Application for Funding Insulin Pumps and Supplies for Children

Demande de financement pour pompes à insuline et fournitures pour enfants

Official pagePDFVersion française

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Who can sign the ADP children's insulin pump application?

An endocrinologist, another specialist physician, or a nurse practitioner associated with a paediatric diabetes program in the Network of Ontario Paediatric Diabetes Programs. They certify the child has type 1 diabetes, a clinical need for pump therapy and participation in diabetes education, and they give the program's name and ADP clinic number.

How does the children's form differ from the adult insulin pump form?

The adult form, 4537-67E, requires a year of basal/bolus experience and self-management skills such as carbohydrate counting. The children's form instead confirms routines: glucose checks before meals and bedtime, site rotation, sick-day management with no more than one DKA in six months, clinic visits and pump education.

Who pays for a child's insulin pump supplies?

ADP pays an annual grant toward pump supplies, in four equal quarterly instalments, to the payee named in Section 3. The grant covers only part of the cost and can't be used for blood glucose monitor supplies; some private insurers cover supply costs beyond the grant.