Try for free

Ontario ADP Adult Insulin Pump Application (4537-67E)

Ontario's Assistive Devices Program uses this application to pay for an ADP-listed insulin pump and give an annual grant toward pump supplies for adults with type 1 diabetes. An endocrinologist, specialist physician or nurse practitioner linked to an ADP-registered adult diabetes education program confirms five eligibility criteria. The pump starts with a 90-day trial, and supplies funding is renewed yearly.

Who completes it

An endocrinologist or other specialist physician or nurse practitioner associated with an adult diabetes program completes Section 2 and signs Section 4, naming the diabetes education program. The applicant or agent signs Section 3 and the proof of delivery, and the vendor records the pump's make, model and serial number.

Submitting and payment

How to submit it
The ADP-registered diabetes education program helps complete the form, which is submitted to ADP at the start of the 90-day trial; ADP doesn't consider attachments. ADP aims to review a properly completed form within six weeks.

Good to know

  • Applicants need at least one year of basal/bolus insulin experience and must show carbohydrate counting, correction bolus and sick-day skills; the experience criterion doesn't apply to supplies-only requests.
  • The form asks for the number of severe hypoglycaemia episodes in the past 12 months and the date the 90-day pump trial began.
  • ADP pays 100% of the approved pump price directly to the vendor. Supplies are covered by an annual grant paid to the applicant quarterly, which can't be used for glucose monitor supplies.
  • If the 90-day trial isn't successful, the pump goes back to the vendor and ADP cancels the application. Pumps have a 5-year replacement period and at least a 5-year warranty.

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 Adults

Demande de financement pour pompes à insuline et fournitures pour adultes

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.

See how Vero Documents works

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 insulin pump application for adults?

An endocrinologist, another specialist physician, or a nurse practitioner associated with one of the adult diabetes programs. They certify the applicant has type 1 diabetes, has shown a clinical need for pump therapy and has taken part in a diabetes education program, and they give the program's name and ADP clinic number.

How does the ADP 90-day insulin pump trial work?

Once the diabetes team finds the applicant suitable, the application is submitted at the start of a 90-day trial. After approval, the vendor supplies the pump and the first supplies grant instalment arrives. If the trial isn't successful, the pump is returned, the vendor credits ADP, and the person can reapply later.

Does the adult insulin pump supplies grant need renewing?

Yes. ADP mails a renewal form every year, which the applicant completes with their diabetes assessment team and returns to keep receiving the quarterly supplies grant. Original receipts for the pump and supplies must be kept for at least 2 years after purchase in case ADP asks for proof.