Individual Authorizer Equipment Evaluation Request Form

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Instructions

The Equipment Evaluation Group (EEG) reviews requests for new equipment to be added to the list of devices that can be authorized as communication aids by the Assistive Devices Program (ADP) in Ontario.The EEG meets twice a year (May and November) to review requests.If you would like to request a new device for the Individual Authorizer Product Manual please complete the following form.

You must be an Individual Authorizer (OT or SLP) to request equipment evaluation
Fill out information on form below and click to submit request.
If you have questions please email CEP: info@mail.cepp.org

Individual Authorizer Equipment Evaluation Request Form

Date of submission(Required)

ADP Auth. Number(Required)

IA Name(Required)

First Last

IA Address(Required)

Street Address City Province Postal Code

Phone(Required)

Email(Required)

Employer

Device Information and Rationale

Device Name(Required)

Device Manufacturer(Required)

Device cost (Cd'n $)(Required)

Suggested Device Type(Required)

Indication OT or SLP Authorization

SLP

Provide a brief description of product and it's purpose.

List any features that aren't met by other goods in the product manual. Why should this device be added based on your clinical experience?

What experience do you have with this equipment you are requesting?

Seller / Distributer Information (Ontario Vendor Required)

Name(Required)

Address(Required)

Street Address City Province Postal Code

Phone(Required)

Email(Required)

Name

This field is for validation purposes and should be left unchanged.