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3203E (2016/06) © Queen's Printer for Ontario, 2016 Disponible en français Page 1 of 2
Ministry of Children, Community and Social Services Ontario Disability Support Program
ODSP Hearing Aid Benefit (Exceptional Circumstances)
Instructions
Only a Registered Assistive Devices Program (ADP) Hearing Aid Authorizer may complete this form and must provide the following:
• a copy of the Hearing Aid Benefit Authorization Form; and
• a completed Hearing Aid Benefit (Exceptional Circumstances) form, including:
- a description of service(s)/device(s)/item(s) being requested;
- the cost of the service(s)/device(s)/item(s) being requested;
- the clinical determination and rationale for requesting the service(s)/device(s)/item(s); and
- the applicant’s signature in section D.All Exceptional Circumstances Requests are reviewed by MCCSS ODSP Hearing Aid Benefit Program (Exceptional Circumstances) .
A registered ADP Authorizer must send the information above to the following:
Ministry of Children, Community and Social Services ODSP Hearing Aid Benefit Program (Exceptional Circumstances) 77 Wellesley Street West Box 460 Toronto ON M7A 1N3
Once received, the Ministry will review the request and send both you and the applicant a letter about the decision.
Section A – Applicant InformationLast Name First Name Middle Initial
Date of Birth (yyyy/mm/dd) Member ID Hearing Aid Benefit Authorization Form Invoice Number
Section B – Registered ADP Hearing Aid Authorizer Information and ADP Vendor InformationADP Authorizer Name ADP Vendor Name and Registration Number
ADP Registration Number CASLPO or AHIP Member Number
Vendor AddressUnit Number Street Number Street Name PO Box
City/Town Province Postal Code
Telephone Number Fax Number Email Address
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3203E (2016/06) Page 2 of 2
Section C – Request: Exceptional Circumstances
Pre-authorization and approval from the ODSP Hearing Aid Benefit Program (Exceptional Circumstances) must be obtained before dispensing or providing service(s)/ device(s)/ item(s) requested under the Exceptional Circumstances policy.
Please complete the sections below:
Description of Services(s)/ Device(s)/ Item(s) Requested
Clinical Determination and Rationale
Cost
Signature of Registered ADP Hearing Aid Authorizer Date (yyyy/mm/dd)
NOTE: The Criminal Code of Canada s.s. 380 (1) states that everyone who by deceit, falsehood or other fraudulent means defrauds the public of any property, money or valuable security, is guilty of an offence. The Ontario Disability Support Program Act, 1997, Sec. 59 states a person who knowingly receives a benefit or assistance that he/she is not entitled to receive under the Act and regulations is guilty of an offence.
Section D – Applicant Declaration & Consent for Release of Information Important: The application will not be processed if the Declaration and Consent is not signed.The person applying for the Hearing Aid Benefit (Exceptional Circumstances), or someone lawfully authorized to sign on their behalf, must sign this declaration and consent for release of information.
If the application under the Hearing Aid Benefit (Exceptional Circumstances) is for a child under 16, then the declaration and consent for release of information must be signed by the social assistance applicant/recipient or other individual with lawful custody of the child.
I declare to the best of my knowledge, that the information on this form is true, correct and complete. I consent to the release of information outlined in this application to the Ministry of Children, Community and Social Services (“ministry”). I also consent to the release, by the service provider who has completed this application, to the ministry of any information in my records relating to the information provided on this application form. I understand that the ministry would be using this information to determine my eligibility for the Hearing Aid Benefit (Exceptional Circumstances).
I further consent to the release of my personal information by the ministry to the service provider in connection with the administration of the Hearing Aid Benefit (Exceptional Circumstances).
I have read and signed this consent freely and voluntarily.
Signature of applicant or other lawfully authorized individual Date (yyyy/mm/dd)
The Notice with Respect to the Collection of Personal Information (Freedom of Information and Protection of Privacy Act)
This information is collected under the legal authority of the Ontario Disability Support Program Act, 1997, sections 5, 10, 45 & 46 for the purpose of administering the Ontario Disability Support Program. For more information, please contact name, title
at , in your local
Ontario Disability Support Program Office.
Hearing Aid Benefit (Exceptional Circumstances)�Section A – Applicant Information�Section B – Registered ADP Hearing Aid Authorizer Information�Section C – Request: Exceptional Circumstances�Section D – Applicant Declaration and Consent for Release of Information�
3203E (2016/06) © Queen's Printer for Ontario, 2016
Disponible en français
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3203E (2016/06)
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Hearing Aid Benefit (Exceptional Circumstances)
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Government of Ontario
Ministry of Children,
Community and Social Services
Ontario Disability Support Program
ODSP Hearing Aid Benefit
(Exceptional Circumstances)
Instructions
Only a Registered Assistive Devices Program (ADP) Hearing Aid Authorizer may complete this form and must provide the following:
• a copy of the Hearing Aid Benefit Authorization Form; and
• a completed Hearing Aid Benefit (Exceptional Circumstances) form, including:
- a description of service(s)/device(s)/item(s) being requested;
- the cost of the service(s)/device(s)/item(s) being requested;
- the clinical determination and rationale for requesting the service(s)/device(s)/item(s); and
- the applicant’s signature in section D.
All Exceptional Circumstances Requests are reviewed by MCCSS ODSP Hearing Aid Benefit Program (Exceptional Circumstances) .
A registered ADP Authorizer must send the information above to the following:
Ministry of Children, Community and Social Services ODSP Hearing Aid Benefit Program (Exceptional Circumstances) 77 Wellesley Street West Box 460 Toronto ON M7A 1N3
Once received, the Ministry will review the request and send both you and the applicant a letter about the decision.
Section A – Applicant Information
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Section A – Applicant Information
Section B – Registered ADP Hearing Aid Authorizer Information
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Section B – Registered ADP Hearing Aid Authorizer Information and ADP Vendor Information
Vendor Address
Section C – Request: Exceptional Circumstances
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Section C – Request: Exceptional Circumstances
Pre-authorization and approval from the ODSP Hearing Aid Benefit Program (Exceptional Circumstances) must be obtained before dispensing or providing service(s)/ device(s)/ item(s) requested under the Exceptional Circumstances policy.
Please complete the sections below:
NOTE: The Criminal Code of Canada s.s. 380 (1) states that everyone who by deceit, falsehood or other fraudulent means defrauds the public of any property, money or valuable security, is guilty of an offence. The Ontario Disability Support Program Act, 1997, Sec. 59 states a person who knowingly receives a benefit or assistance that he/she is not entitled to receive under the Act and regulations is guilty of an offence.
Section D – Applicant Declaration and Consent for Release of Information
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Section D – Applicant Declaration & Consent for Release of Information Important: The application will not be processed if the Declaration and Consent is not signed.
The person applying for the Hearing Aid Benefit (Exceptional Circumstances), or someone lawfully authorized to sign on their behalf, must sign this declaration and consent for release of information.
If the application under the Hearing Aid Benefit (Exceptional Circumstances) is for a child under 16, then the declaration and consent for release of information must be signed by the social assistance applicant/recipient or other individual with lawful custody of the child.
I declare to the best of my knowledge, that the information on this form is true, correct and complete. I consent to the release of information outlined in this application to the Ministry of Children, Community and Social Services (“ministry”). I also consent to the release, by the service provider who has completed this application, to the ministry of any information in my records relating to the information provided on this application form. I understand that the ministry would be using this information to determine my eligibility for the Hearing Aid Benefit (Exceptional Circumstances).
I further consent to the release of my personal information by the ministry to the service provider in connection with the administration of the Hearing Aid Benefit (Exceptional Circumstances).
I have read and signed this consent freely and voluntarily.
The Notice with Respect to the Collection of Personal Information
(Freedom of Information and Protection of Privacy Act)
This information is collected under the legal authority of the Ontario Disability Support Program Act, 1997, sections 5, 10, 45 & 46 for the purpose of administering the Ontario Disability Support Program. For more information, please contact name, title
at
, in your local
Ontario Disability Support Program Office.
8.0.1291.1.339988.308172
ODSP Hearing Aid Benefit (Exceptional Circumstances)
MCCSS
ODSP Hearing Aid Benefit (Exceptional Circumstances)
MCCSS
MCCSS
Section A – Applicant Information. Date of Birth.Enter date in format: year: 4 digits, month: 2 digits, day: 2 digits. Or select date from the drop down calendar (press down arrow to open the calendar, use the arrow keys to navigate by keyboard)
Vendor Address. Postal Code.Enter Postal Code in format: letter, digit, letter, digit, letter, digit.
Signature of Registered ADP Hearing Aid Authorizer. Date.Enter date in format: year: 4 digits, month: 2 digits, day: 2 digits. Or select date from the drop down calendar (press down arrow to open the calendar, use the arrow keys to navigate by keyboard)
Section D – Applicant Declaration & Consent for Release of Information. Date.Enter date in format: year: 4 digits, month: 2 digits, day: 2 digits. Or select date from the drop down calendar (press down arrow to open the calendar, use the arrow keys to navigate by keyboard)
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