Application for Funding Mobility Devices

1 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)

2 I am eligible to receive coverage for Mobility Devices from:Workplace Safety & Insurance Board (WSIB)YesNoVeterans Affairs Canada (VAC) Group AYesNoSection 2 Devices and Eligibility (to be completed by Authorizer)Applicant's presenting medical condition - Must Be CompletedApplicant s basic functional Mobility status related to the need for an ADP funded device - Must Be CompletedMobility Equipment Previously Funded by ADP (check one or more as appropriate)NoneForearm crutchesPower add on devicePower recline systemWheeled walkerPower scooterPower elevating leg restsManual wheelchairPositioning Devices (seating)Paediatric standing framePower wheelchairPower tilt systemPaediatric specific specialty strollerThis page must be completed and submitted2196-67E (2016/04) Page 2 of 12 Applicant's Last NameFirst NameHealth Number (10 digits)VersionDevice(s) Currently Required by the Applicant on an ongoing daily basis, Based on Eligibility Criteria for ADP Funding AssistanceComplete and submit the relevant Section(s) below:(check one or more as appropriate)Forearm crutches only to achieve independent Mobility .

3 Section 2aA wheeled walker only to achieve independent Mobility ..Section 2aA manual wheelchair only to achieve independent Mobility ..Section 2bAn ambulation aid and a manual wheelchair to achieve independent Mobility ..Section 2a and Section 2bA manual wheelchair to achieve Mobility (dependent for propulsion) ..Section 2bA manual dynamic tilt wheelchair to achieve independent Mobility ..Section 2bA manual dynamic tilt wheelchair to achieve Mobility (dependent for propulsion)..Section 2bA manual wheelchair with a power add-on device to achieve independent Mobility ..Section 2bA power base only to achieve independent Mobility ..Section 2cA power scooter only to achieve independent Mobility .

4 Section 2cAn ambulation aid and a power base/scooter to achieve independent Mobility ..Section 2a and Section 2cPositioning Devices (seating) for a wheelchair - modular and/or custom fabricated ..Section 2dA high technology power base (dynamic tilt and/or recline and/or power elevating leg rests) attach justification for Funding chart..Section 2cA paediatric standing frame..Section 2aModifications to previously ADP funded device(s)..Section 2a/ambulation aid, Section 2b/manual wheelchair, Section 2c/power wheelchairModifications to non ADP funded device(s)..Section 2a/ambulation aid, Section 2b/manual wheelchair, Section 2c/power wheelchairThis page must be completed and submitted2196-67E (2016/04) Page 3 of 12 Applicant's Last NameFirst NameHealth Number (10 digits)VersionSection 2a Ambulation AidsBase Device (check one walker and/or forearm crutches and/or one paediatric standing frame)

5 Adult Wheeled Walker Type 1 Adult Wheeled Walker Type 2 Adult Wheeled Walker Type 3 Paediatric Specific Wheeled Walker Type 1 Paediatric Specific Wheeled Walker Type 2 Paediatric Specific Wheeled Walker Walking FramePaediatric Standing Frame Type 1 Paediatric Standing Frame Type 2 Forearm CrutchesNoneReason for Application (check one)First access for Mobility DevicesAnother type of device required in addition to Previously ADP Funded Device(s)Modifications to Non ADP Funded Device(s)Replacement of Previously ADP Funded Device(s) no longer in useModifications/Adjustments/Additional Components to Previously ADP Funded Device(s) currently in useReplacement Device(s) and/or Modifications Required Due To: (check as appropriate)Change in applicant s Mobility status - previously ADP funded equipment no longer meeting basic Mobility needs as defined by ADP for Funding purposesChange in applicant s body size - previously ADP funded equipment is either too large or too ADP funded equipment is worn out - attach vendor quote and/or copies of repair bills for wheeled walkers and wheelchairs circumstances - none of the above - attach letter of of Applicant s Eligibility for Ambulation Aids (answer required for each statement)1.

6 Applicant requires the prescribed device in order to move throughout his/her place of Applicant requires the prescribed device in order to move beyond his/her place of Applicant requires the prescribed device to access wheelchair inaccessible areas in his/her place of Applicant is independently mobile with the prescribed Applicant requires forearm Applicant requires a paediatric specific standing 2a continued2196-67E (2016/04) Page 4 of 12 Applicant's Last NameFirst NameHealth Number (10 digits)VersionPrescription Details for Wheeled Walker Only: (answers required for all specifications)1.

7 Seat HeightcmorinchesN/A2. Push Handle Heightcmorinches3. Hand GripsNone StandardAnatomicalForearm AttachmentsOneTwo4. Width Between Push Handlescmorinches5. Client Weightkgorlbs6. BrakesNonePush -To-LockAuto Stop7. Brake TypeNoneBilateralOne Hand8. Number of WheelsTwoThreeFour9. Wheel Size4-6 inches6-8 inches8-10 inches10. Back SupportYesNoAdditional ADP Funded Options Required for Prescribed Device (if applicable check one or more)Adolescent Size Paediatric Specific Wheeled WalkerAdolescent Size Paediatric Wheeled Walker Walking FrameAdolescent Size Paediatric Standing FrameNon ADP Funded Options Prescribed (Optional)Set Up Instructions for Vendor (Optional)Custom Modifications RequiredThe authorizer must provide clinical rationale to support the request in the space below and attach a vendor quote that provides a breakdown of the cost of labour (not to exceed $ ) and (2016/04)

8 Page 5 of 12 Applicant's Last NameFirst NameHealth Number (10 digits)VersionSection 2b Manual WheelchairsBase Device (check one)Adult Standard Manual WheelchairAdult Lightweight Standard Manual WheelchairAdult Lightweight Performance Manual WheelchairAdult High Performance Rigid Manual WheelchairAdult Manual Dynamic Tilt WheelchairPaediatric Lightweight Standard Manual WheelchairPaediatric Lightweight Performance Manual WheelchairPaediatric High Performance Rigid Manual WheelchairPaediatric Manual Dynamic Tilt WheelchairPaediatric Specific Specialty StrollerNonePower Add-On Device Requested (check in addition to base device if required)Reason for Application (check one)

9 First access for Mobility DevicesAnother type of device required in addition to Previously ADP Funded Device(s)Modifications to Non ADP Funded Device(s)Replacement of Previously ADP Funded Device(s) no longer in useModifications/Adjustments/Additional Components to Previously ADP Funded Device(s) currently in useReplacement Device(s) and/or Modifications Required Due To: (check as appropriate)Change in applicant s Mobility status - previously ADP funded equipment no longer meeting basic Mobility needs as defined by ADP for Funding purposesChange in applicant s body size - previously ADP funded equipment is either too large or too ADP funded equipment is worn out - attach vendor quote and/or copies of repair bills for wheeled walkers and wheelchairs circumstances - none of the above - attach letter of of Applicant s Eligibility for A Manual Wheelchair: (answer required for each statement)1.

10 Applicant requires the use of a manual wheelchair to move throughout his/her place of residence and can move independently throughout his/her place of residence with the prescribed Applicant requires the use of a manual wheelchair to move beyond his/her place of residence and can move independently beyond his/her place of residence with the prescribed Applicant requires the use of a manual wheelchair to move throughout his/her place of residence and is dependent on attendant for Applicant requires the use of a manual wheelchair to move beyond his/her place of residence and is dependent on attendant for Applicant requires the use of a titanium frame wheelchair to move independently throughout his/her place of Applicant requires the use of a titanium frame wheelchair to move independently beyond his/her place of Applicant can weight shift independently in the sitting Applicant demonstrates a history of tissue trauma and/or a significant risk of tissue trauma when sitting and skin integrity cannot be maintained with the addition of fixed seating Applicant cannot maintain a functional posture in sitting due to abnormal tone and/or joint contractures and posture cannot be supported with the addition of fixed seating Applicant demonstrates an intolerance for