Try for free

ADP Maxillofacial Extraoral Prostheses Form (4821-67E)

Ontario's Assistive Devices Program uses this application to fund custom-made facial prostheses (auricular, nasal, orbital, orbitomaxillary and nasomaxillary) for people with a long-term physical disability needing one for at least six months. A specialist physician examines the applicant and refers to a restorative prosthetist registered as an ADP authorizer, who completes and submits the form. ADP pays 75% of the approved price.

Who completes it

A specialist physician, such as an ophthalmologist, plastic surgeon, oncologist or otolaryngologist, signs Section 4 certifying a chronic physical disability requiring regular use of the prosthesis. The ADP-registered restorative prosthetist selects the prosthesis and confirms eligibility, 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 notifies the vendor once funding is approved.

Good to know

  • The authorizer confirms the applicant needs a prosthesis as a substitute for a partially or totally absent facial part, and marks each device as new or repeat.
  • ADP doesn't fund a second prosthesis for the same facial site, ocular or intraoral prostheses, implants or posts, repairs, or prostheses made outside Ontario or by non-registered vendors.
  • Replacement may be funded for a change in medical condition, growth or atrophy, or deterioration that jeopardizes the applicant's condition, but not after loss, theft or misuse.
  • The vendor warrants fit for two years and guarantees against discolouration or deterioration for six months, providing service free of charge during the warranty.

Get the official form

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

Application for Funding Maxillofacial Extraoral Prostheses

Demande de financement Prothèses maxillo-faciales extra-buccales

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

Which physicians can sign the ADP maxillofacial extraoral prostheses form?

ADP says applicants must be examined by a specialist physician: an ophthalmologist, plastic surgeon, oncologist or otolaryngologist. That physician refers the person to a restorative prosthetist registered with ADP as an authorizer, and signs the physician certification with their six-digit OHIP billing number.

How much does ADP pay for a facial prosthesis?

ADP pays 75% of its approved price to the registered vendor and the applicant pays 25%; for people receiving Ontario Works, ODSP or ACSD, ADP may pay 100%. If the prosthesis is ordered before approval and ADP then refuses funding, the applicant owes the vendor the full amount.

Is an artificial eye covered by this ADP form?

No. Ocular prostheses have their own ADP application, 4658-67E, and intraoral prostheses use 4820-67E. This form covers custom-made auricular, nasal, orbital, orbitomaxillary and nasomaxillary prostheses, whether new or replacements for previously funded ones.