Transcription of Application for Funding Mobility Devices
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Application for Funding Mobility Devices
2196-67E (2016/04) Queen's Printer for Ontario, 2016 Disponible en fran aisPage 1 of 12 Ministry of Health and Long-Term Care Assistive Devices Program (ADP) 5700 Yonge Street, 7th Floor Toronto ON M2M 4K5 Tel: 416 327-8804 Toll-Free: 1 800 268-6021 TTY: 416 327-4282 TTY: 1 800 387-5559 Application for Funding Mobility DevicesSection 1 Applicant s Biographical InformationLast NameFirst NameMiddle InitialHealth Number (10 digits)VersionDate of Birth (yyyy/mm/dd)GenderMaleFemaleName of Long-Term Care Home (LTCH) (if applicable)AddressUnit NumberStreet NumberStreet NameLot/Concession/Rural RouteCity/TownProvincePostal CodeHome Telephone NumberBusiness Telephone of BenefitsI am receiving social assistance benefitsYesNoIf yes, please check oneOntario Works Program (OWP)Ontario Disability Support Program (ODSP)Assistance to Children with Severe Disabilities (ACSD)
2196-67E (2016/04) Page 3 of 12. Applicant's Last Name. First Name. Health Number (10 digits). Version
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