Ministry of Health
and Long-Term Care

Assistive Devices Program (ADP)
5700 Yonge Street, 7th Floor
Toronto ON  M2M 4K5

Application for Funding Insulin
Pumps and Supplies for Children

Section 1 – Biographical Information

PLEASE PRINT

Last Name

     

First Name

     

Middle Initial

   

Address

Type (St./Blvd/Ave/Dr/Crt)

Direction

Suite/Apt.

Building Number

     

Street Name

     

Ave./Dr./Crt.)

    

(N/S/W/E)

    

Number

     

Lot/Concession/Rural Route

     

City/Town

     

ON

Postal Code

     

Health Number

     

Version Code

     

Date of Birth (dd/mm/yyyy)

     /        /       

Sex

 Male  Female

Home Telephone (include area code)

(           )          

Business Telephone (include area code)

(           )                      Ext.      

 

Section 2 – Confirmation of Eligibility

To be completed by an Endocrinologist or another Specialist Physician who is associated with one of the paediatric diabetes programs that are part of the Network of Ontario Paediatric Diabetes Programs (NOPDP)

In order to confirm eligibility for ADP funding assistance the applicant/family must agree to ALL of the following criteria:

Completion of an insulin pump education program                            Yes

Blood glucose monitoring before each meal and before bedtime         Yes

Ongoing recording of the blood glucose test results                        Yes

Appropriate insertion site rotation                                                 Yes

Appropriate sick day management                                                Yes

Regular attendance at diabetes clinic (at least 3 times/year)             Yes

 

Number of episodes of DKA in last 12 months             #       N/A

 

Provide the last two A1c results

1.   Date (dd/mm/yyyy)

          /        /       

A1c

     

2.  Date (dd/mm/yyyy)

          /        /       

A1c

     

Date insulin pump therapy was initiated

Indicate make and model of the insulin pump prescribed

Date (dd/mm/yyyy)

     /        /       

Make

     

Model

     

I certify that the above named person has type 1 diabetes and has demonstrated a clinical need for insulin pump therapy and has participated in a diabetes education program.

Physician’s Signature

Last name, First name (please print)

Date (dd/mm/yyyy)

    /      /      

OHIP Billing Number

     

Name and Address of Paediatric Diabetes Program/Team providing education

Program/Team Name

     

ADP Clinic Number

     

Address

Type (St./Blvd./

Direction

Suite/Apt.

Lot/Concession/

Building Number

     

Street Name

     

Ave./Dr./Crt.)

    

(N/S/W/E)

    

Number

     

Rural Route

     

City/Town

     

ON

Postal Code

     

Business Telephone (include area code)

(           )                      Ext.      

Section 3 – Equipment Request & Specifications

Check one box only:

  Insulin Pump and Supplies, (Section 3 must be completed by insulin pump vendor)
  Insulin Supplies Only (Complete Section 5)

Description of Item (Make & Model)

     

Serial Number

     

ADP Device Code

     

ADP Price

$      

Vendor Name

     

ADP Registration Number

     

I hereby certify that the equipment as prescribed has been provided to the applicant.

Vendor Representative

Last Name

     

First Name

     

Invoice Number

     

Vendor’s Representative Signature

Date (dd/mm/yyyy)

    /      /      

Business Telephone (include area code)

(       )            Ext.      

Section 4 – Proof of Delivery

To be completed and signed by the applicant, parent or agent

I confirm that I have received the insulin pump described in Section 3

Signature

 Applicant     Parent  Agent

Date (dd/mm/yyyy)

     /        /       

Section 5 – Consent/Authorization
Consent/Authorization

The Ministry of Health and Long-Term Care’s (the Ministry) collection of the personal health information on this form is necessary for the purposes of assessing and verifying eligibility for the Assistive Devices Program, and for all other purposes related to the proper administration of that Program.

This information may be used or disclosed in accordance with the Personal Health Information Protection Act 2004, as set out in the Ministry’s “Statement of Information Practices” which is accessible at: www.health.gov.on.ca.

Applicants may withhold their consent to the collection of this information; however, doing so will interfere with their coverage under the Assistive Devices Program.

For more information on the Ministry’s Information Practices, or the collection of the personal health information on this form,
call 1-800-2680-6021 or 416-327-8804 or write to the Program Manager, 5700 Yonge Street, 7 th Floor, Toronto ON M2M 4K5.

NOTE: This form may only be signed by the applicant, parent or agent.

I certify that the information I have provided on this form is true, correct and complete to the best of my knowledge.  I understand that this information is subject to audit.

Signature

 Applicant     Parent  Agent

Date (dd/mm/yyyy)

     /        /       

If signature above is not that of the applicant, complete payee information below.
If person other than parent is signing, copy of legal documents must be enclosed.

PLEASE PRINT

Name of Payee

Last Name

     

First Name

     

Middle Initial

   

Address of Payee

Type (St./Blvd./

Direction

Suite/Apt.

Building Number

     

Street Name

     

Ave./Dr./Crt.)

    

(N/S/W/E)

    

Number

     

Lot/Concession/Rural Route

     

City/Town

     

ON

Postal Code

     

Signature

Home Telephone (include area code)

(           )          

Date (dd/mm/yyyy)

     /        /