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ADP Power Tilt/Recline Justification Chart (5023-67E)

Ontario's Assistive Devices Program requires this justification chart when a mobility application requests a high-technology power base with power dynamic tilt, power recline or power elevating leg rests. The ADP-registered mobility authorizer reports objective findings from trials of each equipment set-up. The chart is attached to the Application for Funding Mobility Devices (2196-67E), and the equipment comes from ADP's Central Equipment Pool.

Who completes it

The ADP-registered mobility authorizer, an occupational therapist or physiotherapist, completes the whole chart with the applicant's name, health card number and the authorizer's assessment date. The chart has no physician or applicant signature section.

Submitting and payment

How to submit it
Attach the chart to the mobility devices application (2196-67E), which is submitted to ADP once the applicant or agent, authorizer and vendor have signed. It is one of the few attachments ADP accepts with that form.

Good to know

  • For each trial set-up, record skin integrity, respiratory function, postural alignment, maximum sitting tolerance with time, independent mobility, lower extremity edema, and caregiver availability and requirements.
  • Power wheelchairs with power dynamic tilt or recline, including additions to an existing chair, must be obtained through ADP's Central Equipment Pool for High Technology Wheelchairs.
  • The Central Equipment Pool supplies discounted and recycled high-technology wheelchairs, rebates the client's costs when equipment is returned, and covers routine maintenance and repairs.
  • ADP pays 75% of the approved price, or 100% for people on Ontario Works, ODSP or ACSD, and the authorizer must inform the applicant about Central Equipment Pool policies.

Get the official form

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

Power Dynamic Positioning Devices - Justification for Funding Chart

Dispositifs de positionnement dynamique électriques - Tableau justificatif pour financement

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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

When is the ADP power dynamic positioning justification chart required?

Whenever the mobility devices application requests a high-technology power base with power dynamic tilt, power recline or power elevating leg rests. Section 2 of form 2196-67E directs the authorizer to attach this justification chart, and the submission checklist lists it as an accepted attachment.

Who completes the power tilt and recline justification chart?

The ADP-registered mobility authorizer, an occupational therapist or physiotherapist who assessed the applicant's functional mobility and trialled the equipment. The chart records objective findings for each trial set-up, such as skin integrity and sitting tolerance, and rows can be added to compare several configurations.

Where does a power tilt or recline wheelchair come from?

From ADP's Central Equipment Pool for High Technology Wheelchairs. All system components, including positioning devices, go through the pool, which provides discounted and recycled equipment, free routine maintenance and repairs, and a rebate on the client's costs once the equipment is returned.