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ADP Form 4792-67E: Ventilator Equipment Funding

Ontario's Assistive Devices Program uses this application for home ventilators, bilevel units with a backup rate (BPAP-ST), oxygen saturation monitors for patients 18 or younger, mechanical in-exsufflation devices and ventilator supplies. The prescribing physician confirms device-specific medical criteria. The physician then submits it with the Addendum (5063-67E) to ADP's Ventilator Equipment Pool, which loans the equipment free of charge.

Who completes it

Only a physician completes Section 2 (Devices and Diagnosis) and signs Section 4, certifying long-term need and that the applicant has been trained on the equipment, with a 6-digit OHIP billing number. The applicant or agent completes Section 1, including benefit and residence questions, and signs Section 3.

Submitting and payment

How to submit it
The physician helps complete this form and the Addendum (5063-67E), then submits both to the Ventilator Equipment Pool for processing. Supporting documentation is attached only where the form asks for it, such as a sleep-related BPAP-ST diagnosis.
Who pays
The form sets no physician fee; equipment from the Ventilator Equipment Pool is loaned free of charge, and supplies are funded through an annual grant paid to the patient every 3 months.

Good to know

  • Not eligible: long-term care home residents, acute or chronic care hospital inpatients, and people already covered by WSIB or Veterans Affairs Canada for the same equipment.
  • The patient must need a ventilator or related equipment for 6 months or longer, and coverage is renewed every 2 years on a form ADP sends near the anniversary.
  • Oxygen saturation monitors are limited to patients 18 or younger who are technology dependent, cannot alert a caregiver, risk profound hypoxemia, and whose physician has privileges at a listed hospital.
  • Mechanical in-exsufflation needs a neuromuscular, post-polio, spinal cord or similar weak-muscle diagnosis and documented peak cough flow under 270 L/min with lung volume recruitment or assisted cough.

Get the official form

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

Application for Funding Ventilator Equipment and Supplies

Demande de financement Équipement et matériel pour ventilateur

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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

Where does the ADP ventilator application go?

Ontario's program page says the physician submits this application and the Addendum (5063-67E) to ADP's Ventilator Equipment Pool for processing. If funding is denied, the pool tells the physician, who can help with next steps including an appeal; if approved, the pool contacts the patient to arrange delivery.

Can a nurse practitioner complete the ventilator application?

No. Section 2 is marked to be completed by a physician, and Section 4 has only a physician signature block with a 6-digit Ontario Health Insurance billing number. The physician certifies the chronic respiratory illness or disability and that the applicant has been instructed and trained on the equipment.

What does BPAP-ST approval require?

The physician confirms a chronic respiratory illness needing a BPAP-ST device with a backup rate, states whether there is a diagnosis of obstructive sleep apnea, obesity hypoventilation or central sleep apnea (with supporting documentation if so), and confirms the patient or family knows the device is not for life support.