What the 4392-67 is for
The grant helps pay for external silicone breast prostheses for people with one or both breasts totally or partially absent. That includes after a mastectomy or lumpectomy, after a failed reconstruction following one, or with a congenital deformity. Income isn’t considered. People who already qualify for coverage of the same prosthesis through WSIB, or Group A veterans covered by Veterans Affairs Canada, aren’t eligible. Prosthetic limbs use a different ADP form and a different process.
Who completes it
The applicant completes all three sections, or an agent such as a spouse, parent, legal guardian, the Public Trustee or a power of attorney. There’s no part for a clinician.
Usually the patient fills in the form at home with the receipt in hand and phones or visits to confirm the details of their surgery. In Medulla, you can fill in what the chart supports, such as the health number and the type and month of each surgery, then send the form to the patient over a secure link. They add the purchase details from their receipt and complete Section 3 on the same PDF, and send it back as one finished application.
How to fill in the medical details
Section 1: Biographical information and benefits
The applicant’s name, 10-digit health number and version, date of birth, address and phone, and the long-term care home if they live in one. They confirm whether they receive Ontario Works, ODSP or ACSD, and whether they’re eligible for coverage from WSIB or Veterans Affairs Canada Group A.
Section 2: Devices and eligibility
The applicant records full or partial, purchase date and cost for each side, and the reason: first access, or replacement because of a change in body size or shape, a change in medical condition, or normal wear out of warranty. Under medical eligibility, they tick a congenital breast deformity, or mastectomy or lumpectomy with the year and month of surgery for each side. This is where the chart helps, since the surgery type and date must be right for each side.
Section 3: Consent and signature
The applicant or agent signs and dates the consent and certification. An agent gives their relationship and contact details.
Common reasons it’s declined
- A prosthesis that isn’t silicone, or a temporary or swim prosthesis.
- More than one prosthesis per side.
- A replacement for normal wear less than two years after the last approval, or still under warranty.
- Reconstruction failure without a prior mastectomy or lumpectomy.
- Coverage already available through WSIB or Veterans Affairs.
- Supporting documents attached, which the form says ADP won’t consider.
Submitting and who pays
The patient buys the prosthesis from a business with trained fitters and pays the full cost first, keeping the receipt for two years. They send the form to ADP by email to assistivedevicesprogram@opddp.ca, by fax to 416-327-8192, or by mail to 5700 Yonge Street, 7th Floor, Toronto ON M2M 4K5. ADP aims to decide within eight weeks and pays within 30 days of approval, by cheque or direct deposit.