Special Diet Form Odsp Pdf [extra Quality] File

☐ Short-term (less than 6 months – specify end date: _______________) ☐ Long-term (6+ months or permanent)

| Diet Component | Check if required | Monthly Additional Cost ($) | |----------------|------------------|-----------------------------| | Gluten-free | ☐ | $ ______ | | Low Lactose / Lactose-free | ☐ | $ ______ | | Low Sodium (≤1500mg/day) | ☐ | $ ______ | | Low Potassium (Renal) | ☐ | $ ______ | | Low Phosphorus (Renal) | ☐ | $ ______ | | Pureed (Dysphagia) | ☐ | $ ______ | | Liquid / Supplemental (e.g., Ensure, Boost) | ☐ | $ ______ | | High Protein / High Calorie | ☐ | $ ______ | | PKU / Metabolic formula | ☐ | $ ______ | | Other (specify): __________ | ☐ | $ ______ | special diet form odsp pdf

(Explain why this specific diet is medically necessary for this patient): Specific Dietary Modifications Required (e.g., gluten-free, low potassium, pureed, high-calorie supplement): Expected Duration of Diet (choose one): ☐ Short-term (less than 6 months – specify

Ministry of Children, Community and Social Services Ontario Disability Support Program (ODSP) SECTION 1: PERSONAL INFORMATION (To be completed by the applicant) | Field | Information | |-------|-------------| | Full Legal Name | _________________________ | | ODSP Member ID | _________________________ | | Date of Birth (YYYY-MM-DD) | _________________________ | | Home Address | _________________________ | | Postal Code | _________________________ | | Telephone Number | _________________________ | | Caseworker’s Name (if known) | _________________________ | SECTION 2: TYPE OF SPECIAL DIET REQUESTED Check all that apply. You must have a medical diagnosis requiring this diet. special diet form odsp pdf

☐ Yes ☐ No SECTION 4: DIETARY PRESCRIPTION & MONTHLY COSTS (To be completed by prescriber) Check the applicable ODSP approved special diet components and indicate monthly estimated extra cost.