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Ontario ADP Ocular Prostheses Application (4658-67E)

Ontario's Assistive Devices Program uses this application to fund custom ocular prostheses, scleral lens prostheses, trial shells, conformers and related procedures such as recolouring, adjustments and impressions under anaesthesia. Applicants need the prosthesis for six months or longer because of a long-term physical disability. A physician or optometrist prescribes, and an ADP-registered ocularist authorizes and submits the form.

Who completes it

A physician or optometrist signs the prescriber certification after an in-person assessment, confirming a chronic physical disability requiring regular use of the ocular prosthesis. The ADP-registered authorizer, a certified ocularist or dispensing optician, completes Section 2 and signs, the applicant or agent signs Section 3, and the vendor signs.

Submitting and payment

How to submit it
The authorizer submits the completed form to ADP, which aims to review a properly completed application within six weeks and then notifies the vendor to arrange delivery.

Good to know

  • Applicants must be examined by an ophthalmologist, general practitioner or optometrist; the general practitioner or ophthalmologist refers them to an ADP-registered authorizer certified by the National Examining Board of Ocularists.
  • ADP doesn't fund a second prosthesis for the same side while the first still works, hydroxyapatite implants and attachment posts, or repairs to prostheses, conformers and scleral lenses.
  • Choose one reason per side: first access, replacement for growth or atrophy, change in medical condition or normal wear, or modifications and devices.
  • The vendor must give a written three-month fit warranty and a one-year warranty against discolouration and separation of materials under normal use.

Get the official form

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

Application for Funding Ocular Prostheses

Demande de financement Prothèses oculaires

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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

Can an optometrist sign the ADP ocular prostheses form?

Yes. The prescriber's certification can be signed by a physician or an optometrist who assessed the applicant in person, with the physician's or optometrist's six-digit Ontario Health Insurance billing number. The authorizer who selects the prosthesis must be an ADP-registered certified ocularist or dispensing optician.

How much does ADP pay for an artificial eye?

ADP pays 75% of its approved price to the registered vendor and the applicant pays the remaining 25%; for people receiving Ontario Works, ODSP or ACSD, ADP may pay 100%. Non-funded options cost extra, and ADP doesn't pay for repairs or maintenance.

When will ADP fund a replacement ocular prosthesis?

When the orbital cavity or socket size has changed, when growth or atrophy makes the current prosthesis unusable, or when deterioration jeopardizes the applicant's medical condition. The contribution depends on past ADP funding, and ADP doesn't replace prostheses that are lost, stolen or damaged through misuse.