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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)I am eligible to receive coverage for Mobility Devices from.

2196-67E (2016/04) Page 2 of 12. Applicant's Last Name. First Name. Health Number (10 digits). Version

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