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
ADP Form 4823-67E: Pressure Modification Devices
Ontario's Assistive Devices Program uses this application to fund pressure garments and custom orthoses for hypertrophic scars, compression garments and sleeves for chronic lymphedema, and sequential extremity pumps for primary lymphedema. Clinicians meet it when a patient needs one of these devices for at least six months of regular daily use. A specialist physician examines the patient, an ADP-registered authorizer assesses, and the registered vendor sends the signed form to ADP.
Who completes it
The physician or nurse practitioner fills in the Section 2 diagnosis (hypertrophic scarring or primary or secondary chronic lymphedema, plus any surgery and its date) and signs Section 4 with an OHIP billing number. The applicant completes Sections 1 and 3, the ADP-registered authorizer completes Section 2a or 2b, and the authorizer, certified fitter and vendor each sign their own Section 4 block.
Submitting and payment
- How to submit it
- Once the applicant or agent, prescriber, authorizer, fitter and vendor have signed, the ADP-registered vendor submits the form to ADP. ADP does not consider attachments, and its program page sets an 8-week review target.
- Who pays
- Neither the form nor its information sheet lists a fee for the prescriber; ADP pays the registered vendor 75% of the approved device price, or up to 100% for Ontario Works, ODSP or ACSD recipients.
Good to know
- For first access a specialist must examine the patient: a plastic surgeon, physiatrist or general surgeon on an ADP-registered burn team for scars, or a lymphedema team member for pumps.
- Not funded: devices for post-operative use or under six months, acute conditions, venous insufficiency or thromboembolism, implanted devices, pressure inserts, dressings, and elastic wraps or bandages.
- For lymphedema garments and sleeves, the specialist, family physician or nurse practitioner must complete a new assessment every 2 years or when the medical condition changes.
- The fillable PDF is an XFA form that browsers and older Adobe Reader versions, including Reader XI, cannot open properly; use a current Adobe Acrobat or Reader.
Get the official form
Download the current version from the source each time; forms change without notice.
Application for Funding Pressure Modification Devices
Demande de financement Dispositifs de modification de la tension
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.
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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
Which physicians can examine a patient for ADP lymphedema garments?
ADP's information sheet lists vascular, plastic, general, orthopaedic and cardiovascular surgeons, medical and radiation oncologists, internal medicine specialists, paediatricians, physiatrists, gynecologic oncologists, general practitioners in oncology, wound care specialists and experienced dermatologists. Sequential extremity pumps need a specialist who belongs to an ADP-registered lymphedema team.
How often does ADP replace compression garments?
Hypertrophic scar garments can be replaced as needed up to five sets of two outfits in 12 months, and lymphedema garments up to three sets. Identical replacements during the 2-year funding period need no new form, but a size or style change requires a new application and new assessments.
Who pays for pressure garments under ADP?
ADP pays the registered vendor 75% of the ADP-approved price and the patient pays the remaining 25%. Ontario Works, ODSP and Assistance to Children with Severe Disabilities recipients may have up to 100% covered. Options ADP does not fund are paid to the vendor, and devices ordered before approval are the patient's cost if funding is refused.