ADP Application

ADP Application

Section 1 – Applicant’s Biographical Information

Sex
I am receiving social assistance benefits
If yes, please check one
I am eligible to receive coverage for Mobility Devices from Workplace Safety & Insurance Board (WSIB)
I am eligible to receive coverage for Mobility Devices from Veterans Affairs Canada (VAC) – Group A

Section 2 – Devices and Eligibility (to be completed by Authorizer)

Mobility Equipment Previously Funded by ADP (check one or more as appropriate)
Device(s) Currently Required by the Applicant on an ongoing daily basis, Based on Eligibility Criteria for ADP Funding Assistance, Complete and submit the relevant Section(s) below: (check one or more as appropriate)

Section 2a – Ambulation Aids

Base Device (check one walker and/or forearm crutches and/or one paediatric standing frame)
Reason for Application (check one)
Replacement Device(s) and/or Modifications Required Due To: (check as appropriate)
Confirmation of Applicant’s Eligibility for Ambulation Aids (answer required for each statement)
1: Applicant requires the prescribed device in order to move throughout his/her place of residence.
2: Applicant requires the prescribed device in order to move beyond his/her place of residence.
3: Applicant requires the prescribed device to access wheelchair inaccessible areas in his/her place of residence.
4: Applicant is independently mobile with the prescribed device.
5: Applicant requires forearm crutches.
6: Applicant requires a paediatric specific standing frame.
Prescription Details for Wheeled Walker Only: (answers required for all specifications)
Units
Units
Hand Grips
Forearm Attachments
Units
Weight Units
Brakes
Brake Type
Number of Wheels
Wheel Size
Back Support
Additional ADP Funded Options Required for Prescribed Device (if applicable check one or more)
The 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 $40.00/hour) and parts.

Section 2b – Manual Wheelchairs

Base Device (check one)
Reason for Application (check one
Replacement Device(s) and/or Modifications Required Due To: (check as appropriate)
Confirmation of Applicant’s Eligibility for A Manual Wheelchair: (answer required for each statement)
1: 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 device.
2: 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 device.
3: Applicant requires the use of a manual wheelchair to move throughout his/her place of residence and is dependent on attendant for propulsion.
4: Applicant requires the use of a manual wheelchair to move beyond his/her place of residence and is dependent on attendant for propulsion.
5: Applicant requires the use of a titanium frame wheelchair to move independently throughout his/her place of residence.
6: Applicant requires the use of a titanium frame wheelchair to move independently beyond his/ her place of residence.
7: Applicant can weight shift independently in the sitting position.
8: 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 alone.
9: 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 alone.
10: Applicant demonstrates an intolerance for sitting which cannot be increased for mobility with the addition of fixed seating alone.
11: Applicant is able to propel a manual wheelchair independently but requires some daily use of power to move throughout his/her place of residence.
12: Applicant is able to propel a manual wheelchair independently but requires some daily use of power to move beyond his/her place of residence.
13: It is anticipated that the applicant will be able to use a manual wheelchair with a power add-on device for his/her long-term mobility needs and will not require the use of a power wheelchair/ power base within the designated funding period.
Prescription Details for Manual Wheelchair Only: (answers required for all specifications)
Units
Units
Units
Units
Units
Units
Weight Unit
Additional ADP Funded Options Required for Prescribed Manual Wheelchair: (check one or more)
Note: See product manual for details about all generic device types.
The 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 $40.00/hour) and parts.

Section 2c – Power Bases and Power Scooters

Base Device (check one)
Reason for Application (check one)
Replacement Device(s) and/or Modifications Required Due To: (check as appropriate)
Confirmation of Applicant’s Eligibility for a Power Base (answer required for each statement)
1: Applicant requires the use of a power base to move independently throughout his/her place of residence.
2: Applicant requires the use of a power base to move independently beyond his/her place of residence.
Confirmation of Applicant’s Eligibility for a Power Scooter (answer required for each statement)
1: Applicant requires the use of a power scooter to move independently throughout his/her place of residence.
2: Applicant requires the use of a power scooter to move independently beyond his/her place of residence.
3: Applicant operates the prescribed scooter independently with the standard scooter seat and tiller.
Prescription Details for Power Device Only (answers required for 1-6 for power base and 6 only for power scooters)
Units
Units
Units
Units
Units
Units
Additional ADP Funded Options Required for Prescribed Power Base (check one or more)
Checkboxes
Provide clinical rationale for the following Specialty Components in space below*
The 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 $40.00/hour) and parts.

Section 2d – Positioning Devices (Seating) for Mobility

Devices and Options
Seat Cushion
Seat Cushion Cover(s)
Seat Option(s)
Seat Hardware
Pommel/Adductors
Pommel Hardware
Back Support
Back Support Options
Back Cover
Back Hardware
Complete Assembly
Headrest/Neckrest
Headrest/Neckrest Options
Headrest/Neckrest Hardware
Positioning Belts
Positioning Belt Options
Arm Support(s)
Arm Support Options
Arm Support Hardware
Tray
Tray Options
Lateral Support(s)
Lateral Support Options
Lateral Support Hardware
Foot/Leg Support(s)
Foot/Leg Support Options
Foot/Leg Support Hardware
Reason for Application (check one)
Replacement Device(s) and/or Modifications Required Due To: (check as appropriate)
Confirmation of Applicant’s Eligibility for a Positioning Devices – Seating (answer required for each statement)
1: Applicant requires the seating components to provide postural support and/or pressure relief during mobility. Applicant can maintain a functional posture during mobility with the seating components prescribed.
2: Applicant requires the tray prescribed to provide postural support during mobility and/or to support an ADP approved communication aid required during mobility.
The 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 $40.00/hour) and parts.

Section 4 – Signatures

Pages and Attachments Being Submitted
Note to ADP Registered Authorizer:
1. Complete this application form in full according to applicant’s eligibility for ADP funding assistance and make a copy for your records.
2. Check the following pages/sections of the application form and the attachments that are included with your submission:
3. Attachments (if required) Note: Other attachments will not be considered by the Assistive Devices Program
4. Application form may be submitted to ADP once all signatures are obtained – applicant/agent, authorizer and vendor(s).
Authorizer’s Signature
I hereby certify that I have personally assessed the applicant named on this form in person, I have confirmed his/her eligibility for funding assistance in accordance with all ADP funding guidelines, I have authorized the equipment described on this form based on a comprehensive clinical assessment, and have taken all safety and environmental concerns into consideration. I have advised the applicant or his/her agent that (i) he/she may purchase the ADP approved equipment from the ADP Registered Vendor of their choice, and have provided a list of ADP Registered Vendors in the applicant’s community for their use or (ii) have informed the applicant or his/her agent about the policies and procedures of the ADP Central Equipment Pool for High Technology Wheelchairs (CEP).
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