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Ontario OMRP Application Form (4882-83E)

Ontario's Oral and Maxillofacial Rehabilitation Program funds implants that retain a removable maxillofacial intraoral prosthesis when no other treatment exists, typically after major jaw reconstruction for trauma or tumour surgery. Referring providers complete sections 1 to 3 and send the form to a program site, where an ADP authorizer and an oral and maxillofacial surgeon assess eligibility. The prosthesis itself is funded through ADP.

Who completes it

The referring provider, such as a physician, surgeon or dentist, completes sections 1 to 3: patient information, referring provider details and medical information. Program clinicians complete the rest, including the ADP authorizer's eligibility section, the program lead's confirmation and any review sections.

Submitting and payment

How to submit it
Send the completed form to one of the four OMRP service delivery sites in Toronto, London or Ottawa listed on the form, with diagnostic reports, images, operative reports and relevant investigations.

Good to know

  • Applicants must be 18 or older with a valid Ontario health card; younger patients apply through the Cleft Lip and Palate / Craniofacial Program instead.
  • Patients should generally be cancer free for one year before referral. Print clearly, since the program returns incomplete or illegible forms.
  • OMRP doesn't fund routine dental care or implants for fixed devices or dentures. Prostheses must be listed in ADP's product manual and made by an ADP-registered vendor.
  • Section 3 asks for the diagnosis type (tumour, trauma, acquired deformity or congenital abnormality), details of any major jaw reconstruction, and the current mandible or maxilla prosthesis.

Get the official form

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

Oral and Maxillofacial Rehabilitation Program (OMRP) Application

Présentation d'une demande au Programme de réhabilitation orale et maxillo-faciale (PROM)

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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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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 is eligible for Ontario's Oral and Maxillofacial Rehabilitation Program?

Adults 18 or older with a valid Ontario health card who qualify for an ADP maxillofacial intraoral prosthesis and, in the opinion of an ADP authorizer and an oral and maxillofacial surgeon, can't retain it, are suitable for implant surgery, and have no other treatment alternative. Most have had major jaw reconstruction after trauma or tumour surgery.

What should a referring provider attach to the OMRP application?

As much detail as possible, including photographs and diagnostic images, previous operative reports, and relevant investigations or lab values; section 3 lets you mark each as available or attached. The instructions also say that if you believe the patient won't meet the eligibility criteria, you should not make the referral.

What if the program finds the patient ineligible?

The form provides for a request for review: a second ADP authorizer reviews eligibility, and if the patient is still ineligible, a third review by committee can follow. Patients found eligible receive a program case number, which is recorded on their ADP funding application for the prosthesis.