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Ministry of Health Ministre
de la Sant
And Long-Term Care et
des Soins de longue dure
_______________________________________________________________________________________
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Operational
Support Branch Assistive
Devices Program 5700 Yonge
Street, 7th Floor Toronto ON M2M 4K5 |
Direction du soutien oprationnel Programme
dÕappareils et accessoires fonctionnels 5700, rue Yonge, 7me tage Toronto (ON) M2M 4K5 |
Telephone: 416-327-8804 Fax: 416-327-8192 Toll Free:
1-800-268-6021 T.D.D.:
1-800-387-5559 T.D.D.: 416-327-4282 |
Tlphone 416-327-8804 Tlcopieur: 416-327-8192 Sans frais: 1-800-268-6021 A.T.S. : 1-800-387-5559 A.T.S. : 416-327-
4282 |
Assisitive
Devices Program (ADP)
Insulin
Pump and Supplies Program
Special
Authorization Form
Applicant
Information
Client Name:
__________________ (last) __________________ (first)
Date of Birth:
____ (day) ______ (month) ______ (year)
Health Card
Number: ___________________________
Take this form
to your Endocrinologist or another Specialist Physician to confirm the
following:
This
individual is no longer being followed by a Paediatric Diabetes Program
Reason: Age
Limitation
Geographical
distance prohibitive
Other Please Explain: ____________________________________________
__________________________________________________________
Your
Endocrinologist or another Specialist Physician must complete Section 2 of the
Application for Funding Insulin Pumps and Supplies for Children form.
Leave the The ÔADP
Clinic NumberÕ section blank.
This form must
be attached to your Application for Funding Insulin Pumps and Supplies for
Children form and submitted to the Assistive Devices Program.
______________________________________ PhysicianÕs
Name:
Sidra
Rizvi
___________________________
Senior Program Analyst (A)
Assistive Devices Program PhysicianÕs
Signature:
Ministry of Health and Long-Term Care
5700 Yonge Street, 7th Floor ___________________________
Toronto, ON M2M 4K5
Phone -
416-327-8178 ADP Use Only:
Fax - 416-327-8192
sidra.rizvi@moh.gov.on.ca