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ADP Form 5063-67E: Ventilator Application Addendum

The prescribing physician completes this addendum alongside the Application for Funding Ventilator Equipment and Supplies (4792-67E) so ADP's Ventilator Equipment Pool can process the request. It records the primary and secondary diagnosis, the exact equipment and settings to supply, and where the equipment should be delivered. Both documents travel together to the pool.

Who completes it

The prescribing physician completes all four sections and signs; the form states it is to be completed by the prescribing physician to facilitate processing a ventilator request. The applicant's consent and signature belong on the main 4792-67E application.

Submitting and payment

How to submit it
Send it with the 4792-67E application: Ontario's ventilator page says the physician submits both to the Ventilator Equipment Pool for processing.
Who pays
No fee is printed on the addendum; equipment from the Ventilator Equipment Pool is loaned to eligible patients free of charge.

Good to know

  • Section 2 diagnoses include ALS, muscular dystrophy, diaphragm paralysis, spinal cord injury, SMA, kyphoscoliosis, drug or neurological respiratory drive depression, obesity hypoventilation, complicated or CPAP-intolerant OSAS, and COPD.
  • Section 3 records ventilator quantity, circuit type, settings and interface (mask, mouthpiece or tracheostomy), BPAP-ST timing, pressures and rate, humidifiers, and daily hours of ventilation.
  • Saturation monitors are approved for a maximum of 2 years: the physician gives start and end dates plus high and low SpO2 and heart rate alarm settings.
  • Section 4 directs delivery to the client's home or to a facility, with the facility name, contact person, floor and room number.

Get the official form

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

Addendum for Ventilator Equipment and Supplies Application Form

Official pagePDF

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Frequently asked questions

Is the 5063-67E addendum required for ADP ventilator funding?

Ontario's ventilator equipment page tells physicians to complete the application form and the application form addendum and to submit both to the Ventilator Equipment Pool. The addendum itself says it is completed by the prescribing physician to facilitate processing a request for ventilator equipment and supplies.

Which software opens the ventilator addendum?

It is an XFA fillable PDF. In a browser or most PDF viewers it shows only a message that Adobe Reader 8 or higher is required, and the Central Forms Repository warns that older Adobe Reader versions, including Reader XI, no longer work. Use a current Adobe Acrobat or Reader.