Form 3111E (2018/12), Ontario Works / Ontario Disability Support Program (ODSP) Application for Special Diet Allowance Instructions

Check this box if the medical condition requiring a special diet is an allergy to milk or dairy. Fill only if 'Registered Midwife or a Traditional Aboriginal Midwife recognized and accredited by their Indigenous community' is 'No'.

Check this box if the special diet for an allergy to milk/dairy is required for 6 months. Fill only if 'Allergy to milk/dairy' is 'Yes'.

Check this box if the special diet for an allergy to milk/dairy is required for 12 months. Fill only if 'Allergy to milk/dairy' is 'Yes'.

Check this box if the special diet for an allergy to milk/dairy is required indefinitely (no end date). Fill only if 'Allergy to milk/dairy' is 'Yes'.

Enter the health care professional’s initials to confirm the medical condition of allergy to milk/dairy. Fill only if 'Allergy to milk/dairy' is 'Yes'.

Check this box if the special diet is required due to an allergy to wheat. Fill only if 'Registered Midwife or a Traditional Aboriginal Midwife recognized and accredited by their Indigenous community' is 'No'.

Check this box if the special diet for an allergy to wheat is required for 6 months. Fill only if 'Allergy to wheat' is 'Yes'.

Check this box if the special diet for an allergy to wheat is required for 12 months. Fill only if 'Allergy to wheat' is 'Yes'.

Check this box if the special diet for an allergy to wheat is required indefinitely. Fill only if 'Allergy to wheat' is 'Yes'.

Enter the health care professional’s initials to confirm the medical condition (allergy to wheat). Fill only if 'Allergy to wheat' is 'Yes'.

Enter the applicant's date of birth.

Enter the applicant's Member ID number.

Enter the applicant's last name (family name).

Enter the applicant's first name (given name).

Enter the applicant's middle initial, if applicable.

Check this box if you are the recipient (you are applying for yourself).

Check this box if you are applying on behalf of your spouse who is the recipient.

Check this box if you are applying on behalf of a dependent child or dependent adult who is the recipient.

Enter the unit, suite, or apartment number for the approved health care professional's address, if applicable.

Enter the street/civic number for the approved health care professional's address.

Enter the street name for the approved health care professional's address.

Enter the city, town, or municipality for the approved health care professional's address.

Enter the province for the approved health care professional's address.

Enter the postal code for the approved health care professional's address.

Enter the approved health care professional's telephone number.

Enter the approved health care professional's fax number.

Enter the first name of the approved health care professional completing this section.

Enter the last name of the approved health care professional completing this section.

Enter the middle initial (if any) of the approved health care professional completing this section.

Check this box if the medical condition requiring a special diet is celiac disease. Fill only if 'Registered Midwife or a Traditional Aboriginal Midwife recognized and accredited by their Indigenous community' is 'No'.

Check this box if the special diet is required for celiac disease for 6 months. Fill only if 'Celiac disease' is 'Yes'.

Check this box if the special diet is required for celiac disease for 12 months. Fill only if 'Celiac disease' is 'Yes'.

Check this box if the special diet is required for celiac disease indefinitely. Fill only if 'Celiac disease' is 'Yes'.

Enter the initials of the health care professional confirming the medical condition that requires a special diet for celiac disease. Fill only if 'Celiac disease' is 'Yes'.

Check this box if the applicant has Chronic hepatitis C with BMI less than 25 and requires a special diet.

Check this box if the special diet for Chronic hepatitis C (BMI < 25) is required for 6 months. Fill only if 'Chronic hepatitis C (BMI < 25)' is 'Yes'.

Check this box if the special diet for Chronic hepatitis C (BMI < 25) is required for 12 months. Fill only if 'Chronic hepatitis C (BMI < 25)' is 'Yes'.

Enter the health care professional’s initials to confirm the applicant has Chronic Hepatitis C (BMI < 25) requiring a special diet. Fill only if 'Chronic hepatitis C (BMI < 25)' is 'Yes'.

Check this box if the applicant’s medical condition is chronic wounds (Stage 1 & 2) or burns affecting 1–10% of body surface area and they require a special diet.

Check this box if the special diet is required for 6 months for chronic wounds (Stage 1 & 2) or burns (1–10% body surface area). Fill only if 'Chronic wounds (Stage 1 & 2) or burns (1–10% body surface area)' is 'Yes'.

Check this box if the special diet is required for 12 months for chronic wounds (Stage 1 & 2) or burns (1–10% body surface area). Fill only if 'Chronic wounds (Stage 1 & 2) or burns (1–10% body surface area)' is 'Yes'.

Check this box if the special diet is required indefinitely for chronic wounds (Stage 1 & 2) or burns (1–10% body surface area). Fill only if 'Chronic wounds (Stage 1 & 2) or burns (1–10% body surface area)' is 'Yes'.

Enter the health care professional’s initials to confirm the diagnosis of chronic wounds (Stage 1 & 2) or burns covering 1–10% of body surface area. Fill only if 'Chronic wounds (Stage 1 & 2) or burns (1–10% body surface area)' is 'Yes'.

Check this box if the applicant’s medical condition is chronic wounds (Stage 3 & 4) or burns affecting more than 10% of body surface area and requires a special diet.

Check this box if the special diet for chronic wounds (Stage 3 & 4) or burns (>10% body surface area) is required for 6 months. Fill only if 'Chronic wounds (Stage 3 & 4) or burns (>10% body surface area)' is 'Yes'.

Check this box if the special diet for chronic wounds (Stage 3 & 4) or burns (>10% body surface area) is required for 12 months. Fill only if 'Chronic wounds (Stage 3 & 4) or burns (>10% body surface area)' is 'Yes'.

Check this box if the special diet for chronic wounds (Stage 3 & 4) or burns (>10% body surface area) is required indefinitely. Fill only if 'Chronic wounds (Stage 3 & 4) or burns (>10% body surface area)' is 'Yes'.

Enter the health care professional’s initials to confirm the chronic wounds (Stage 3 & 4) or burns (>10% body surface area) medical condition. Fill only if 'Chronic wounds (Stage 3 & 4) or burns (>10% body surface area)' is 'Yes'.

Check this box if the person has a congenital heart defect and has had a Ross procedure or arterial switch procedure, or has coexisting coarctation of the aorta. Fill only if 'Registered Midwife or a Traditional Aboriginal Midwife recognized and accredited by their Indigenous community' is 'No'.

Check this box if the special diet for the congenital heart defect is required for 6 months. Fill only if 'Congenital heart defect (Ross/arterial switch or coarctation of aorta)' is 'Yes'.

Check this box if the special diet for the congenital heart defect is required for 12 months. Fill only if 'Congenital heart defect (Ross/arterial switch or coarctation of aorta)' is 'Yes'.

Check this box if the special diet for the congenital heart defect is required indefinitely. Fill only if 'Congenital heart defect (Ross/arterial switch or coarctation of aorta)' is 'Yes'.

Enter the health care professional’s initials to confirm the congenital heart defect medical condition requiring a special diet. Fill only if 'Congenital heart defect (Ross/arterial switch or coarctation of aorta)' is 'Yes'.

Check this box if the person has diabetes and requires a special diet allowance for this medical condition. Fill only if 'Registered Midwife or a Traditional Aboriginal Midwife recognized and accredited by their Indigenous community' is 'No'.

Check this box if the diabetes-related special diet is required for 6 months. Fill only if 'Diabetes' is 'Yes'.

Check this box if the diabetes-related special diet is required for 12 months. Fill only if 'Diabetes' is 'Yes'.

Check this box if the diabetes-related special diet is required indefinitely (no expected end date). Fill only if 'Diabetes' is 'Yes'.

Enter the initials of the health care professional confirming the diabetes medical condition. Fill only if 'Diabetes' is 'Yes'.

Check this box if the patient has dysphagia and requires thickened fluids as a special diet. Fill only if 'Registered Midwife or a Traditional Aboriginal Midwife recognized and accredited by their Indigenous community' is 'No'.

Check this box if the thickened-fluids diet is required for 6 months. Fill only if 'Dysphagia requiring thickened fluids' is 'Yes'.

Check this box if the thickened-fluids diet is required for 12 months. Fill only if 'Dysphagia requiring thickened fluids' is 'Yes'.

Check this box if the thickened-fluids diet is required indefinitely (no end date). Fill only if 'Dysphagia requiring thickened fluids' is 'Yes'.

Enter the health care professional’s initials confirming the medical condition requiring thickened fluids for dysphagia. Fill only if 'Dysphagia requiring thickened fluids' is 'Yes'.

Check this box if the person has extreme obesity (Class III) with BMI greater than 40 and requires a special diet allowance for this condition. Fill only if 'Registered Midwife or a Traditional Aboriginal Midwife recognized and accredited by their Indigenous community' is 'No'.

Check this box if the special diet for extreme obesity (Class III BMI>40) is required for 6 months. Fill only if 'Extreme Obesity: Class III BMI>40' is 'Yes'.

Check this box if the special diet for extreme obesity (Class III BMI>40) is required for 12 months. Fill only if 'Extreme Obesity: Class III BMI>40' is 'Yes'.

Check this box if the special diet for extreme obesity (Class III BMI>40) is required indefinitely. Fill only if 'Extreme Obesity: Class III BMI>40' is 'Yes'.

Enter the health care professional’s initials to confirm the diagnosis of extreme obesity (Class III BMI>40) requiring a special diet. Fill only if 'Extreme Obesity: Class III BMI>40' is 'Yes'.

Check this box if the patient has gestational diabetes requiring a special diet (allowance provided during pregnancy and for 3 months post partum). Fill only if 'Registered Midwife or a Traditional Aboriginal Midwife recognized and accredited by their Indigenous community' is 'No'.

Enter the expected delivery date for the pregnancy related to the gestational diabetes special diet allowance. Fill only if 'Gestational Diabetes' is 'Yes'.

Enter the initials of the health care professional confirming the gestational diabetes medical condition. Fill only if 'Gestational Diabetes' is 'Yes'.

Enter the signature of the approved health care professional authorizing the information on this application.

Enter the date the approved health care professional signed this application.

Check this box if the health care professional completing this section is a physician.

Check this box if the health care professional completing this section is a Registered Nurse in the Extended Class.

Check this box if the health care professional completing this section is a Registered Dietitian.

Check this box if the health care professional completing this section is a Registered Midwife or a Traditional Aboriginal Midwife recognized and accredited by their Indigenous community.

Enter or apply the approved health care professional’s stamp information, if available.

Check this box if the patient has hypercholesterolemia/hyperlipidemia that requires a special diet allowance. Fill only if 'Registered Midwife or a Traditional Aboriginal Midwife recognized and accredited by their Indigenous community' is 'No'.

Check this box if the special diet for hypercholesterolemia/hyperlipidemia is required for 6 months. Fill only if 'Hypercholesterolemia/Hyperlipidemia' is 'Yes'.

Check this box if the special diet for hypercholesterolemia/hyperlipidemia is required for 12 months. Fill only if 'Hypercholesterolemia/Hyperlipidemia' is 'Yes'.

Check this box if the special diet for hypercholesterolemia/hyperlipidemia is required indefinitely. Fill only if 'Hypercholesterolemia/Hyperlipidemia' is 'Yes'.

Enter the health care professional’s initials to confirm the Hypercholesterolemia/Hyperlipidemia medical condition. Fill only if 'Hypercholesterolemia/Hyperlipidemia' is 'Yes'.

Check this box if the medical condition requiring the special diet allowance is hypertension. Fill only if 'Registered Midwife or a Traditional Aboriginal Midwife recognized and accredited by their Indigenous community' is 'No'.

Check this box if the special diet for hypertension is required for 6 months. Fill only if 'Hypertension' is 'Yes'.

Check this box if the special diet for hypertension is required for 12 months. Fill only if 'Hypertension' is 'Yes'.

Check this box if the special diet for hypertension is required indefinitely (no end date). Fill only if 'Hypertension' is 'Yes'.

Enter the initials of the health care professional confirming the hypertension medical condition. Fill only if 'Hypertension' is 'Yes'.

Check this box if the infant requires formula because there is an inadequate quantity of breast milk to sustain breast-feeding or breast-feeding is medically contraindicated.

Enter the infant’s date of birth for the special diet allowance request due to inadequate lactation or breast-feeding being contraindicated. Fill only if 'Inadequate lactation to sustain breast-feeding or breast-feeding is contraindicated' is 'Yes'.

Enter the health care professional’s initials to confirm the medical condition requiring the special diet. Fill only if 'Inadequate lactation to sustain breast-feeding or breast-feeding is contraindicated' is 'Yes'.

Check this box if the patient has lactose intolerance that requires a special diet allowance. Fill only if 'Registered Midwife or a Traditional Aboriginal Midwife recognized and accredited by their Indigenous community' is 'No'.

Check this box if the lactose intolerance special diet is required for 6 months. Fill only if 'Lactose intolerance' is 'Yes'.

Check this box if the lactose intolerance special diet is required for 12 months. Fill only if 'Lactose intolerance' is 'Yes'.

Check this box if the lactose intolerance special diet is required indefinitely. Fill only if 'Lactose intolerance' is 'Yes'.

Enter the health care professional’s initials to confirm the lactose intolerance medical condition. Fill only if 'Lactose intolerance' is 'Yes'.

Enter the date the local office received the application.

Enter the local ODSP/OW office stamp information or identifier.

Check this box if the special diet allowance is being requested because the patient has osteoporosis. Fill only if 'Registered Midwife or a Traditional Aboriginal Midwife recognized and accredited by their Indigenous community' is 'No'.

Check this box if the special diet for osteoporosis is required for 6 months. Fill only if 'Osteoporosis' is 'Yes'.

Check this box if the special diet for osteoporosis is required for 12 months. Fill only if 'Osteoporosis' is 'Yes'.

Check this box if the special diet for osteoporosis is required indefinitely (no end date). Fill only if 'Osteoporosis' is 'Yes'.

Enter the health care professional’s initials to confirm the osteoporosis medical condition requiring the special diet. Fill only if 'Osteoporosis' is 'Yes'.

Enter the signature of the applicant or another individual who is lawfully authorized to sign on the applicant’s behalf.

Enter the date on which the applicant or authorized individual signed the declaration and consent.

Enter the name or title of the person or office to contact for more information.

Enter the telephone number for the contact person or office listed for more information.

Check this box if the patient has Prader-Willi Syndrome and requires the Red, Yellow, Green Diet special diet allowance. Fill only if 'Registered Midwife or a Traditional Aboriginal Midwife recognized and accredited by their Indigenous community' is 'No'.

Check this box if the Prader-Willi Syndrome special diet is required for 6 months. Fill only if 'Prader-Willi Syndrome (Red, Yellow, Green Diet)' is 'Yes'.

Check this box if the Prader-Willi Syndrome special diet is required for 12 months. Fill only if 'Prader-Willi Syndrome (Red, Yellow, Green Diet)' is 'Yes'.

Check this box if the Prader-Willi Syndrome special diet is required indefinitely. Fill only if 'Prader-Willi Syndrome (Red, Yellow, Green Diet)' is 'Yes'.

Enter the health care professional’s initials to confirm the Prader-Willi Syndrome (Red, Yellow, Green Diet) medical condition. Fill only if 'Prader-Willi Syndrome (Red, Yellow, Green Diet)' is 'Yes'.

Check this box if the patient has renal failure and is on peritoneal dialysis and/or hemodialysis requiring a special diet.

Check this box if the special diet for renal failure on peritoneal/hemodialysis is required for 6 months. Fill only if 'Renal Failure – peritoneal/hemodialysis' is 'Yes'.

Check this box if the special diet for renal failure on peritoneal/hemodialysis is required for 12 months. Fill only if 'Renal Failure – peritoneal/hemodialysis' is 'Yes'.

Check this box if the special diet for renal failure on peritoneal/hemodialysis is required indefinitely. Fill only if 'Renal Failure – peritoneal/hemodialysis' is 'Yes'.

Enter the initials of the health care professional confirming the renal failure peritoneal/hemodialysis medical condition. Fill only if 'Renal Failure – peritoneal/hemodialysis' is 'Yes'.

Check this box if the patient has renal failure and is in the pre-dialysis stage with a GFR under 30 requiring a special diet.

Check this box if the special diet for renal failure pre-dialysis (GFR < 30) is required for 6 months. Fill only if 'Renal Failure – pre-dialysis (GFR < 30)' is 'Yes'.

Check this box if the special diet for renal failure pre-dialysis (GFR < 30) is required for 12 months. Fill only if 'Renal Failure – pre-dialysis (GFR < 30)' is 'Yes'.

Check this box if the special diet for renal failure pre-dialysis (GFR < 30) is required indefinitely. Fill only if 'Renal Failure – pre-dialysis (GFR < 30)' is 'Yes'.

Enter the health care professional’s initials to confirm the renal failure pre-dialysis (GFR < 30) medical condition. Fill only if 'Renal Failure – pre-dialysis (GFR < 30)' is 'Yes'.

Check this box if the applicant has Rett Syndrome and their BMI is less than 18.5, requiring a special diet.

Check this box if the special diet for Rett Syndrome (BMI < 18.5) is required for 6 months. Fill only if 'Rett Syndrome (BMI < 18.5)' is 'Yes'.

Check this box if the special diet for Rett Syndrome (BMI < 18.5) is required for 12 months. Fill only if 'Rett Syndrome (BMI < 18.5)' is 'Yes'.

Enter the initials of the health care professional confirming the Rett Syndrome (BMI < 18.5) medical condition. Fill only if 'Rett Syndrome (BMI < 18.5)' is 'Yes'.

Enter the total number of medical conditions you have indicated on this application that require a special diet.

Check this box if the applicant has unintended weight loss of more than 5% and up to (and including) 10% due to one or more of the listed other conditions.

Check this box if the applicant has unintended weight loss of more than 10% due to one or more of the listed other conditions.

Check this box if the special diet is required for 6 months for the unintended weight loss due to other conditions. Fill only if 'Unintended weight loss (other conditions): >5% and ≤10% weight loss', 'Unintended weight loss (other conditions): >10% weight loss' is 'Yes' (any).

Check this box if the special diet is required for 12 months for the unintended weight loss due to other conditions. Fill only if 'Unintended weight loss (other conditions): >5% and ≤10% weight loss', 'Unintended weight loss (other conditions): >10% weight loss' is 'Yes' (any).

Check this box if the special diet is required indefinitely for the unintended weight loss due to other conditions. Fill only if 'Unintended weight loss (other conditions): >5% and ≤10% weight loss', 'Unintended weight loss (other conditions): >10% weight loss' is 'Yes' (any).

Enter the initials of the health care professional confirming the unintended weight loss due to other condition(s). Fill only if 'Unintended weight loss (other conditions): >5% and ≤10% weight loss', 'Unintended weight loss (other conditions): >10% weight loss' is 'Yes' (any).

Check this box if the patient has had unintended weight loss due to renal failure (GFR<30) of more than 5% and up to and including 10%.

Check this box if the patient has had unintended weight loss due to renal failure (GFR<30) of more than 10%.

Check this box if the special diet for unintended weight loss due to renal failure is required for 6 months. Fill only if '>5% and ≤10% weight loss', '>10% weight loss' is 'Yes' (any).

Check this box if the special diet for unintended weight loss due to renal failure is required for 12 months. Fill only if '>5% and ≤10% weight loss', '>10% weight loss' is 'Yes' (any).

Check this box if the special diet for unintended weight loss due to renal failure is required indefinitely. Fill only if '>5% and ≤10% weight loss', '>10% weight loss' is 'Yes' (any).

Enter the initials of the health care professional confirming unintended weight loss due to renal failure. Fill only if '>5% and ≤10% weight loss', '>10% weight loss' is 'Yes' (any).