Form Mt-20 - Medical Transportation Reimbursement Form
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1
2
3Health Canada Protected
First Nations and Inuit Health Branch
Non-Insured Health Benefits (NIHB) Program
Medical Transportation Reimbursement Form - Atlantic Region
All requests for reimbursement of eligible benefits must be made within one year from the date of service.
Please submit ALL required documents and keep a copy of this form with all supporting documents for your records.
orms that are unsigned or incomplete will be returned.
F
Call NIHB for prior approval toll-free at 1-800-565-3294, Local (902) 426-2656
NIHB Travel Authorization Number:
Section 1 - Client Information (client receiving the service)
Client=s Full Name :
Date of Birth :
/
/
Client ID # :
dd
/ mm
/ yyyy
Client=s Home Address:
Phone Number: (
)
City:
Prov:
Postal Code:
Non-Medical Escort=s Name (requires prior approval unless client is a minor):
Escort ID# (if applicable):
Are you covered for any of these expenses under any other health plan(s)/program(s)? Yes
No
If YES, please attach a copy of a detailed statement or explanation of benefits form from all other plan(s)/program(s).
Section 2 - Payment Information
Please provide the name and address of the person or organization to which payment should be made. The payee must
be the provincial legal age.
IF PAYEE INFORMATION IS THE SAME AS THE CLIENT INFORMATION CHECK HERE
Cheque payable to:
Address:
City:
Prov:
Postal Code:
Section 3 - Appointment Information
Confirmation of attendance must be completed OR a confirmation from the health facility attached. See page 3 for
additional confirmations. Include the name of the Health Professional seen or the type of diagnostic test
performed. Medical justification is required when travel is beyond the nearest facility. The appointment service must be
insured by your provincial health plan (MCP, MSI, NB Medicare, PEI Medicare) or NIHB for medical transportation.
Appointment Date:
/
/
Appointment Time in:
Appointment Time out
dd
/ mm
/ yyyy
Physician/Health Professional=s Name:
Phone Number:(
)
(print)
Name and Address of Health Facility:
Signature or stamp from Health Facility (mandatory):
Page 1 of 3
MT-20 Last Updated April 2014
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