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ADP Maxillofacial Intraoral Prostheses Form (4820-67E)

Ontario's Assistive Devices Program uses this application to fund maxillofacial intraoral prostheses, such as obturators, palatal lift prostheses, mandibular extension prostheses, acrylic splints and stents, plus relining, adjustments and tissue conditioning. Applicants need a prosthesis for at least six months because of a chronic physical disability. A physician or dentist prescribes, and an ADP-registered prosthodontist or general dentist authorizes and submits the form.

Who completes it

A physician or dentist signs the prescriber certification after an in-person assessment, confirming a chronic physical disability requiring regular use of the prosthesis. The authorizer, a prosthodontist or general dentist registered with ADP, 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.

Good to know

  • Applicants must first be examined by a specialist physician or general surgeon, who refers them to an ADP-registered prosthodontist or general dentist holding a Royal College of Dental Surgeons certificate.
  • ADP excludes implants, repairs, a second prosthesis for the same site, dentures not used to suspend an eligible device, and patients eligible under the Lip/Palate Program.
  • Vendor fees include three months of post-insertion adjustments, and repairs after that are the patient's responsibility; ADP doesn't fund adjustments during those three months.
  • Adults who need implants to retain the prosthesis may qualify for the Oral and Maxillofacial Rehabilitation Program (4882-83E), since ADP itself doesn't fund implants.

Get the official form

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

Application for Funding Maxillofacial Intraoral Prostheses

Demande de financement Prothèses maxillo-faciales intra-buccales

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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

Can a dentist sign the ADP intraoral prostheses form as prescriber?

Yes. The prescriber's signature can come from a physician or a dentist who assessed the applicant in person. The authorizer, who selects the device, must be a prosthodontist or general dentist registered with ADP. ADP also says applicants must first be examined by a specialist physician or general surgeon.

How much does ADP pay for an obturator or other intraoral prosthesis?

ADP pays 75% of its approved price to the registered vendor and the applicant pays 25%, or ADP may pay 100% for people on Ontario Works, ODSP or ACSD. Non-funded options cost extra, and ordering before approval leaves the applicant responsible for the full cost if ADP refuses.

When will ADP replace an intraoral prosthesis?

When a change in medical condition, growth, atrophy or tissue changes make the current prosthesis unusable, when deterioration jeopardizes the applicant's medical condition, or for normal wear once it's out of warranty. ADP doesn't replace prostheses that are lost, stolen or damaged beyond repair through misuse.