Verification of Disability for March of Dimes HVMP Funding Application

Funding application for stairlifts, vertical platform lift, ceiling lift, elevator lift, automatic door opener, custom ramps, accessible home modification, accessible bathroom modification

HVMP Application (PDF Version)

Verification of Disability (PDF Version)

Fill HVMP Application (*Online Version)

*Please note that the online application service is designed to automatically fill out the PDF application form for you. It does not submit the application directly to March of Dimes. You will have the opportunity to download the completed application, which you can then send to March of Dimes. Additionally, a copy of the filled application will be stored on our server and shared with the email addresses you provide.

March of Dimes HVMP Verification of Disability

Applicant Information:

(This is the person applying for funding for modifications adaptations and device)

First Name

Last Name

Preferred Name (if different)

Date of Birth

1. What is the client’s disability?

2. What primary mobility device is the client using in the home?

3. How does their disability impact their ability to independently complete activities of daily living such as eating, bathing, toileting, transferring, and mobility?

4. What is your recommendation of devices, adaptations, or modifications to remove this barrier?

Construction Projects Include:

- Modular Ramps
- Vertical Platform Lifts
- Stairlifts
- Ceiling Track Lifts
- Kitchen adaptations – i.e., rearrangement and lowering or raising of kitchen equipment and cupboards
- Bathroom adaptations – i.e., zero-threshold shower, door widening, waterproof shower panels, grab bars, handheld shower on a slide bar, anti-slip flooring, wheelchair accessible sink, accessible toilet
  - Note: When a bathroom modification is required, but the bathroom structure cannot accommodate a zero-threshold shower, the Program would only consider funding transferable equipment (e.g. a portable roll-in shower) as recommended by an Occupational Therapist.

Please note that equipment is often the most basic and essential solution to removing barriers. Construction projects will only be considered as a last resort and must be recommended by an Occupational Therapist (OT). In order for a construction project to be reviewed for eligibility, an OT must detail basic and essential equipment that has been trialed and explain why it was not suitable.

5. For construction projects please provide a detailed list of equipment that has been trialed and why it was not suitable:

6. If you are recommending bathroom modifications (construction) on the second floor, please describe the mechanics on how the client will manage the stairs safely and independently to access the bathroom located on another level. Please also describe the plan to address the level-to-level change within the home and the long-term plan for the client when they can no longer manage the stairs.

Healthcare Professional’s Information (To contact you about your recommendations for modifications, adaptations and devices)

Ontario Health Regulator Category

Name of Practice

First Name

Last Name

Mailing Address

City & Postal Code

Phone

Email Address (Receive application copy in your email)

Signature

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Verification of Disability for March of Dimes HVMP Funding Application

Applicant Information:

Construction Projects Include:

Healthcare Professional’s Information (To contact you about your recommendations for modifications, adaptations and devices)

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