Fillable Medical Request for Additional Bedroom PART A: TO (City of Toronto)

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Medical Request for Additional Bedroom PART A: TO (City of Toronto)

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23-0
190 2021-05
Page 1 o
f 5
Application
Medical Request for
Additional Bedroom
PART A: TO BE COMPLETED BY ALL APPLICANTS AND THEIR PHYSICIAN OR OTHER
HEALTHCARE PROFESSIONAL
Section 1: Applicant Information
Household Main Applicant First Name
Household Main Applicant Last Name
Telephone Number
Applicant Code
Patient First Name
Patient Last Name
Section 2: Patient Consent
(if the Patient is under 16 years of age, a parent or guardian must complete and sign this section)
I consent to the disclosure of my personal health information by my physician or other health
care professional to Access to Housing for the purposes identified on this form.
Patient or Parent/Guardian First Name
Patient or Parent/Guardian Last Name
Patient or Parent/Guardian Signature
Date (yyyy-mm-dd)
Healthcare Professional Name (First, Last)
Health Care Professional
Telephone Number
Healthcare Professional Address (Street Number, Street Name, Suite/Unit Number, City/Town,
Province, Postal Code)
Important note to healthcare professional and their patient
Households applying for an additional bedroom unit must first have an eligible application on the
Centralized Waiting List for Rent-Geared-to-Income (RGI) housing. You can apply for RGI
housing by visiting www.toronto.ca/accesstohousing.
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
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Application
Medical Request for
Additional Bedroom
23
-0190 2021-
05
Page 2 of 5
The City of Toronto has established local occupancy standards for RGI housing. These standards
permit a household to qualify for an additional bedroom if:
1. A spouse who would normally share a bedroom requires a separate bedroom because of a
disability or medical condition. Spouses will not normally qualify for an additional bedroom
unless a second bed cannot be accommodated within a shared bedroom. A household will
not qualify for an additional bedroom based on a snoring condition alone.
2. A room is required to store equipment that a member of the household needs because of a
permanent disability or medical condition, and the equipment is too large to be reasonably
accommodated in a unit size for which the household would normally qualify.
The following equipment will not normally qualify a household for an additional bedroom:
• Continuous positive airway pressure (CPAP) machines
• Air filtration systems
• Vaporizers or humidifiers
• Walkers, wheelchairs or scooters
• Massage tables
• Exercise equipment
3. A room is required for an individual who provides full-time overnight support services to a
member of the household.
Note: When a household requests an additional bedroom for a medical reason, the RGI
Administrator must determine if the household qualifies under the Local Occupancy Standards.
From time to time, the RGI Administrator may ask for new information to verify that the
household still qualifies for the additional bedroom.
Section 3: Description of need for additional bedroom (To be completed by Healthcare Professional)
How many years has this patient been under your care?
Why does this person with this medical condition or disability need an additional bedroom?
What is the expected duration of the need for the additional bedroom?
No Yes Is the room requested to store medical equipment?
What is the medical equipment to be stored?
Application
Medical Request for
Additional Bedroom
23-0190 2021-05 Page 3 of 5
Section 4: Additional bedroom for a full-time overnight caregiver
Note: Caregiver verification will also be required. Continue to Part B or C
Yes No
Does your patient require a full-time overnight caregiver?
What is the expected duration of their need for an overnight caregiver?
Healthcare Professional Verification
(First, Last)
Signature
Date (yyyy-mm-dd)
Physician's Stamp (if applicable)
Part B: Additional Bedroom for Caregiver not affiliated with Home Care Agency
Section 1: Main Applicant Information
Main Applicant Name (First, Last)
Applicant Code
Applicant Address (Street Number, Street Name, Suite/Unit Number, City, Province, Postal
Code)
Important note to caregivers and those receiving care
The City of Toronto has established Local Occupancy Standards for Rent-Geared-to-Income
housing. These Standards permit a household to have an additional bedroom for an overnight
caregiver who provides full-time support services needed because of a household member’s
disability or medical condition.
When a household requests an additional bedroom for a caregiver, Access to Housing will
determine if the household qualifies under the Local Occupancy Standards. When offered RGI
housing, the Housing Provider (the RGI Administrator) may ask for new information to verify that
the household still qualifies for the additional bedroom.
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Application
Medical Request for
Additional Bedroom
23-0190 2021-05 Page 4 of 5
The personal information disclosed on this form will be used only for the purpose of evaluating the
household’s eligibility for an additional bedroom under the City of Toronto’s Local Occupancy
Standards under the Housing Services Act, 2011. This personal information may also be used for
the purpose of evaluating compliance with the Local Occupancy Standards. The use and
disclosure by Access to Housing of the personal information in this report will be subject to:
• the Housing Services Act, 2011
• in the case of the City of Toronto, the Municipal Freedom of Information and Protection of
Privacy Act
Section 2: Caregiver Information To be completed by Caregiver
Caregiver Name (First, Last)
Caregiver Telephone Number
Yes No
I provide full time overnight care to the applicant listed above.
Yes No
The care I provide enables this applicant to live independently at the address
listed above.
Yes No
I live at this address solely for the purpose of providing care to the applicant
named above.
Yes No
I am currently required, under arrangement with Citizenship and Immigration
Canada, to live with a person who requires care. If yes, attach documentation
from Citizenship and Immigration Canada.
Part C: Additional Bedroom Verification for Caregiver Affiliated with Home Care Agency
Section 1: Main Applicant Information
Main Applicant Name (First, Last)
Application Code
Applicant Address (Street Number, Street Name, Suite/Unit Number, City, Province, Postal
Code)
Section 2: Home Care Agency Information Must be completed by an agency representative
with binding authority.
Agency Name
Agency Address (Street Number, Street Name, Suite/Unit Number, City, Province, Postal Code)
Application
Medical Request for
Additional Bedroom
23-0190 2021-05 Page 5 of 5
Agency Representative Name (First, Last)
Position Title
Telephone Number
Mobile Number
Section 3: Home Care Verification Must be signed by an agency representative.
Yes No
I certify that my agency provides full-time overnight care to the applicant listed
above.
Yes No
The care my agency provides enables this applicant to live independently at the
address listed above.
Agency Representative Name (First, Last - print)
Position/title
Agency Representative Signature
Date (yyyy-mm-dd)
Upload the completed form to the MyAccesstoHousingTO applicant portal.
Shelter, Support and Housing Administration collects personal information on this form under the legal authority of the
Housing Services Act, 2011, section 46 and Ontario Regulation 367/11, General, section 42(1)1. The information is
used to verify the need for an additional bedroom for medical purposes Questions about this collection can be
directed to Project Manager, Access to Housing (Housing Connections), 176 Elm Street, Toronto, Ontario, M5T 3M4
or by telephone at 416-338-8888.
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Medical Request for Additional Bedroom PART A: TO (City of Toronto)

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Completed 22 September 2021

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