Here you can find the forms you may need to prescribe an item under the Rehabilitation Appliances Program (RAP).

Forms

Forms are listed in alphabetical order. Guidelines are available to help you prescribe certain items.

Assistive listening devices

• D9376 - Request for assistive listening devices and/or tinnitus devices (PDF 138 KB)

Communication devices

• D1382 - Request for assistive communication device and/or speech pathology apps/software (PDF 129 KB)

See our guidelines page for more information on how to prescribe communication devices

Continence

• D0988 - Continence direct order form (PDF 120 KB)

For more information on how to prescribe continence products see our guidelines:

• Prescribing continence products (DOCX)
• Prescribing continence products (PDF)

Essential medical equipment

Apply for an annual payment to help with the energy costs of essential medical equipment.

• D1341 - Essential medical equipment medical confirmation form (PDF 310 KB)

Exercise bikes

• D9160 - Request for exercise bike (PDF 150 KB)

Home modifications

• D1323 - Authority to Install form (PDF 136 KB)
• D1327 - Home / Access Modification Assessment Form for all Major Modifications (bathrooms, ramps, lifts etc...) (PDF 249 KB)
• D9299 - Post home modification report (PDF 300 KB)

See our guidelines page for more information on how to prescribe home modifications

Low vision products (CCTV)

• D9257 - Order form for low vision products (PDF 132 KB)

See our guidelines page for more information on how to prescribe CCTV

Mobility & functional support

• D0992 - Mobility and functional support (MFS) products order form (PDF 118 KB)

See our guidelines page for more information on how to prescribe recliner chairs and adjustable electric beds

Oxygen and breathing support

• D0804 - Home medical oxygen therapy and/or respiratory home therapy appliances form (PDF 201 KB)
• D9140 - Application for Positive Airways Pressure (PAP) Equipment(PDF 180 KB)

For more information on how to prescribe see our guidelines:

• oxygen guidlines (DOCX)

Personal Response System (PRS)

• D9199 - Personal Response System (PRS) assessment form (PDF 200 KB)

See our guidelines page for more information on how to prescribe

Assistance Dog - for psychiatric, guide, hearing and mobility dogs

• D9356 - Request for an assistance dog

See our guidelines page for more information on how to prescribe

Request / referral for LMO use

• D0904 - DVA request / referral for LMO use (PDF 140 KB)

Scooters or electric wheelchairs

• D9300 - Scooter / electric wheelchair [Part 1 - medical questionnaire - see also D1325] (PDF 270 KB)
• D1325 - Scooter / electric wheelchair [Part 2 - assessment form - see also D9300] (PDF 380 KB)

See our guidelines page for more information on how to prescribe

Non-nutritional Thickened Fluids

• D9166 - Order form for Non-nutritional Thickened Fluid Products (PDF 200 KB)