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 Orthotic Devices Application (4819-67E)
Ontario's Assistive Devices Program uses this application to fund specified prefabricated and custom-fabricated braces and splints for adults and children with a long-term physical disability needing an orthosis for six months or longer. A physician, nurse practitioner or rehabilitation assessor documents the presenting medical condition, and a board-certified orthotist registered as an ADP authorizer selects the device and submits the form. ADP pays 75% of the approved price.
Who completes it
A physician or nurse practitioner, or an occupational therapist or physiotherapist acting as rehabilitation assessor, records the presenting medical condition in Section 2 and signs Section 4. The orthotist authorizer selects devices and confirms eligibility, the vendor completes modification details and class attestations, and the applicant or agent signs Section 3.
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.
Good to know
- ADP doesn't fund braces needed for under 6 months, braces worn only at night or to rest a body part, shoes or shoe modifications, or treatment machines.
- Each device is assigned a class. Class 2 needs vendor attestation that no Class 1 device would work, and Class 3 needs attestation that neither Class 1 nor Class 2 would.
- The authorizer confirms a long-term physical disability related to the presenting condition and a need for an orthosis daily to improve function in a variety of daily activities.
- Custom adult devices carry a 6-month breakage and 3-month fit warranty; children's custom devices and non-custom devices carry 2 months for breakage and 30 days for fit.
Get the official form
Download the current version from the source each time; forms change without notice.
Application for Funding Orthotic Devices
Demande de financement Orthèses
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 can sign the medical section of the ADP orthotic devices form?
A physician or nurse practitioner who assessed the applicant in person certifies a chronic physical disability requiring regular use of the prescribed orthosis. Alternatively, an ADP-registered occupational therapist or physiotherapist can sign as rehabilitation assessor, confirming the applicant needs the device for a range of daily activities within ADP guidelines.
How do patients get an ADP-funded brace?
A doctor, nurse practitioner, or ADP-registered physiotherapist or occupational therapist examines the applicant and refers them to a Canadian board-certified orthotist registered as an ADP authorizer. If the orthotist finds them eligible, the orthotist completes and submits the form. Equipment ordered before approval is at the applicant's risk if ADP refuses.
How much does ADP pay for orthotic devices?
ADP pays 75% of its approved price and the applicant pays 25%; people on Ontario Works, ODSP or ACSD may get 100% funding. Options ADP doesn't fund cost extra, and ADP doesn't pay for repairs, maintenance, or replacing devices that are lost, stolen or damaged through misuse.