Try for free

Ontario ADP Home Oxygen Renewal Form (5037-67E)

Ontario's Assistive Devices Program uses this form to continue home oxygen funding when an approved funding period ends. The vendor selects the renewal period, from a 30-day short-term extension to 90-day, 9-month or 12-month long-term periods, and new oximetry or exercise results requalify the client. Whether a physician or nurse practitioner must sign depends on the period and the results.

Who completes it

The vendor completes the funding program, delivery system and vendor sections for every applicant. A physician or nurse practitioner completes the diagnosis and signs Section 4A when required, a regulated health professional signs 4B if they did the oximetry, and the applicant or agent signs Section 3.

Submitting and payment

How to submit it
Submit the completed renewal to ADP with signed, dated oximetry print-outs and any supporting documentation the form requires; ADP doesn't consider other attachments.

Good to know

  • For a 9-month long-term renewal, the diagnosis isn't required, and the physician or NP signature is needed only if a complication is indicated or ABG results are provided.
  • Exertional hypoxemia renewals need an Independent or Vendor Exercise Assessment; for 90-day and 12-month periods, a respirologist or internist confirms the results unless they are the prescriber.
  • Signed, dated oximetry print-outs must accompany every renewal except palliative care. If the prescriber didn't do the test, the regulated health professional who did signs Section 4B.
  • In Section 3, the applicant releases the Province from responsibility for damages if the applicant or anyone in the household smokes while using oxygen.

Get the official form

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

Renewal of Funding Home Oxygen Therapy

Renouvellement du financement de l'oxygénothérapie à domicile

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

Does a physician have to sign every ADP home oxygen renewal?

No. The physician or nurse practitioner signature isn't required for the 9-month long-term funding period unless a complication such as cor pulmonale is indicated or ABG results are provided. Other renewals need the prescriber to certify that oxygen remains medically indicated and necessary after other treatment measures were tried without success.

What's the difference between ADP forms 2451-67E and 5037-67E?

Form 2451-67E is for first-time funding, a gap in funding of more than 90 days, or restarting after a prescriber discontinued therapy. Form 5037-67E renews funding when an approved funding period ends, using updated oximetry or exercise results. Both are completed with an ADP-registered home oxygen vendor.

What renewal periods are available for ADP home oxygen?

Short-term oxygen therapy can be extended by 30 days. Long-term therapy for resting hypoxemia renews for 90 days, 9 months or 12 months, and the form also covers long-term therapy for exertional hypoxemia and palliative care. The vendor selects the funding program and delivery system for every applicant.