Download Application for Rehabilitation Assessor/Fitter/Dispenser Status

Application for Rehabilitation
Assessor/Fitter/Dispenser Status
Ministry of Health
and Long-Term Care
Assistive Devices Program (ADP)
5700 Yonge Street, 7th Floor
Toronto ON M2M 4K5
Section 1 – Mailing Address
PLEASE PRINT
Last Name
First Name
Middle Initial
Address
Building Number
Street Name
Lot/Concession/Rural Route
City/Town
Suite/Apt Number
Postal Code
ON
Business Telephone (include area code)
Fax number (include area code)
-
Email Address
-
Section 2 - Details
Device category for which you are applying.
Note: A separate application is required for each category.
(Refer to Attachment A for sub-categories)
Conventional Limb Prostheses (Rehabilitation Assessor)
Externally Powered Upper Limb Prostheses (Rehabilitation Assessor)
Hearing Aids (Dispenser)
Orthotics (Rehabilitation Assessor)
Pressure Modification Devices - Hypertrophic Scar Management (Certified Fitter / Manufacturer Representative)
Pressure Modification Devices - Lymphedema Management (Certified Fitter / Manufacturer Representative)
If you are currently a registered authorizer, fitter, rehabilitation assessor or dispenser with the ADP, specify your authorizer number
Indicate your profession
Audiologist
Certified Fitter
Hearing Instrument Specialist
Hearing Instrument Dispenser
Occupational Therapist
Physiotherapist
Workshop Information
Date (yyyy/mm/dd)
Workshop
/
Date Received (yyyy/mm/dd)
/
/
4637-67E (2011/03)
Approval Date (yyyy/mm/dd)
/
© Queen’s Printer for Ontario, 2011
Location
/
Permanent Number
/
Disponible en français
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Section 3 - Experience
Specify and briefly describe other relevant formal or informal educational programs, workshops, manufacturer’s training programs,
conferences completed/attended in the past 5 years.
Describe your experience in prescribing/assessing/fitting the device for which you are seeking ADP fitter/dispenser status.
Section 4 - Employment Locations (hearing aid dispensers must provide ADP registered vendor address)
Location 1
Employer’s Name
Is this your preferred mailing address
Yes
No (Default to Mailing Address in Section 1)
Address
Building Number
Street Name
Lot/Concession/Rural Route
City/Town
Suite/Apt Number
Postal Code
ON
Business Telephone (include area code)
-
Fax number (include area code)
Email Address
-
Location 2
Employer’s Name
Address
Building Number
Street Name
Lot/Concession/Rural Route
City/Town
Suite/Apt Number
Postal Code
ON
Business Telephone (include area code)
-
Fax number (include area code)
Email Address
-
Location 3
Employer’s Name
Address
Building Number
Street Name
Lot/Concession/Rural Route
City/Town
Suite/Apt Number
Postal Code
ON
Business Telephone (include area code)
-
Fax number (include area code)
Email Address
-
Use Attachment B for additional locations
Section 5 - Confirmation
The information provided on this form is true, correct and complete to the best of my knowledge. I understand that I will have to
sign and comply with the terms specified in the Authorizer Agreement and the Conflict of Interest Protocol.
Date (yyyy/mm/dd)
Signature
X
4637-67E (2011/02)
/
/
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