At home program application 2026

1. Click ‘Get Form’ to open the At Home Program application in the editor.
2. Begin by entering the child's name and date of birth in the designated fields. Ensure that you use the format YYYY/MM/DD for the date.
3. Fill in the address, city/town, area code, phone number, and postal code accurately to ensure proper communication.
4. In the 'Specific Diagnosis' section, provide detailed information about the child's impairment, including type and degree of involvement.
5. List the medical supplies required by entering item names, descriptions/sizes/product numbers, and quantities needed per day.
6. For incontinence supplies (if applicable), include the child’s weight and specify quantities needed per month along with duration required (day/night).
7. Provide a clear justification for each medical supply requested, ensuring it relates directly to the child’s diagnosis. Attach additional pages if necessary.
8. Complete the health care professional's details including their name, profession, contact number, and signature. Don't forget to enter the date signed.
9. Once completed, save your form and follow instructions to mail or fax it to the Medical Benefits Program.

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