MTAP In-Province Medical Transportation Claim – Private Vehicle Only 1General Information2Section 1: Claimant Information3Section 2: Patient Information4Section 3: Details of Medical Travel5Section 4: Supporting Documentation6Section 5: Declaration General Information The Medical Transportation Assistance Program (MTAP) provides financial help to Medical Care Plan (MCP) beneficiaries who incur large out-of-pocket travel costs to access specialized insured medical services which are not available in their area of residence and/or province/country. Eligible costs to claim may include: Economy Airfare Accommodations Meal Allowances Private Vehicle Taxis (when used in conjunction with airfare or bus) Scheduled Transportation Services (e.g., bussing, ferries) Car Rentals – in limited circumstances MTAP is a reimbursement program where patients must pay their medical travel costs upfront before applying to MTAP for financial help. For full details about program eligibility and requirements please visit: Medical Transportation Assistance Program (MTAP) - Labrador Affairs Getting Started Use this form to claim only private vehicle mileage for one or more in-province trips. If you are claiming flights, hotels, or other travel costs for an in-province trip, with or without private vehicle mileage, please use the In-Province Medical Transportation Claim – Flights & Other Travel Costs form. A guide to completing this online form can be found here. You must complete and submit this form in one session. You cannot save it and finish later. To complete this form, you will need the following: Your personal information (MCP number, address, and contact information) Confirmation of attendance for each appointment Confirmation of any insurance provider's explanation of benefits (payout details) for travel Additionally, before you can receive payment for any claim you must be set up as a supplier with the Government of Newfoundland and Labrador. This is only required once, for all payments from Government programs. The supplier setup form is available here. What to Expect After You Submit the Form MTAP staff will review your application. Once processed, you will receive a letter of explanation including a summary of any payments. In the event that MTAP staff require additional information, they will contact you using the information provided on this application. Section 1: Claimant InformationProvide the information of the claimant for this application. The claimant is the individual who will be receiving reimbursement.Name(Required) First Last Phone Number(Required)MCP Number(Required) MCP Expiry Date(Required) Year Month Day Date of Birth(Required) Year Month Day Residential Address(Required) Street Address Address Line 2 City / Town Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Please note that the program is only available to NL residents with a valid MCP number.Mailing Address Same as Residential Address Street Address Address Line 2 City / Town Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Email Preferred Method of Contact Email Phone Mail Please note that all final decisions / payment summaries will be mailed to the claimant. Section 2: Patient InformationPlease enter the information of each patient claiming mileage.Is the claimant also a patient?(Required) Yes No If yes, their information does not need to be entered below.Patient DetailsFirst NameLast NameMCP NumberMCP Expiry Date (YYYY/MM/DD)Relationship to Claimant (e.g. Spouse/Child) Add Remove* The claimant and patient(s) must reside in the same household.Does either patient have private health insurance through their employer or an insurance plan they purchased themselves (e.g., Blue Cross, Canada Life, belairdirect)?(Required) Yes No Note: Medical travel expenses must be reviewed by your private insurer, and the resulting assessment must be submitted with your travel claim to the Department. Check with your insurer before travel to confirm their claim documentation requirements.If Yes, Name of Insurance Provider: Has either patient received, or are they eligible to receive, travel support for this trip from another department, organization (e.g. Hope Air), employer, or government, including the Non-Insured Health Benefits program (NIHB)?(Required) Yes No If Yes, Source of Support AmountIs either patient receiving income support, or home support or financial benefits through the Community Support Program?(Required) Yes No If yes, please contact Medical Transportation Support Program (MeTS) at 1-833-729-6106 for more information about receiving medical travel assistance. Section 3: Details of Medical TravelPlease complete applicable sections below.Private Vehicle MileagePatient MCP*Date of Appointment (YYYY/MM/DD)Starting Location (e.g. City/Facility)Ending Location (e.g. City/Facility)Date(s) of TravelTotal Distance (Both Legs, if Round Trip) Add Remove* MCP number is only required on the first line unless mileage is being claimed for different patients on the same application. Section 4: Supporting DocumentationPlease upload all applicable supporting documentation.Attach/Upload Documents Drop files here or Select files Accepted file types: bmp, doc, docx, gif, heic, jpg, jpeg, pdf, png, tif, tiff Maximum file size per form: 30 MBPlease confirm the following supporting documentation, if applicable, has been included with your claim Confirmation of Attendance for Each Appointment Insurance Provider’s Explanation of Benefits (payout details) for Travel Completed the Supplier Form for Direct Deposit Other Supporting Documentation Select All Section 5: Declaration of Eligibility for Medical Transportation AssistanceThe declaration below must be signed before your claim can be processed. Unsigned claims will be considered incomplete and cannot be reviewed until a completed declaration is received.Privacy statement(Required) I agree to the privacy statement. I declare that the information provided on this claim is true and correct to the best of my knowledge. I understand that this information is collected by the Department of Labrador Affairs pursuant to section 61(1)(c) of the Access to Information and Protection of Privacy Act, 2015, as such information relates directly to and is necessary to, and will be used to determine eligibility for reimbursement of eligible expenses in accordance with the Medical Transportation Assistance Program criteria and conditions, which may include discussions with parties from the Department of Health and Community Services. I declare that I am not eligible for or have not received financial assistance for medical travel from the Department of Social Supports and Well-Being, Department of Health and Community Services, WorkplaceNL, NL Health Services, or any other funding received from an Agency, Board, Commission, organization (e.g., Hope Air), or Provincial/Federal Government program, including the Non-Insured Health Benefits Program. I understand that if I have private health insurance benefits, medical travel expenses must be reviewed by the private insurance provider before submitting a claim to the Department for assessment, and that any monies paid by private insurance must be disclosed in the form of a copy of the private insurance assessment and attached to the claim form. I understand and agree that the information I submit may be subject to verification by officials of the Department of Labrador Affairs and that medical travel assistance provided to me in error is subject to recovery by the Department of Labrador Affairs. I authorize the Department of Labrador Affairs to contact and share information with any other parties identified in this claim for the purpose of verifying medical services received, eligible kilometres, and for auditing purposes. I authorize the Department of Social Supports and Well-Being and/or any other parties identified in this Declaration of Eligibility to release the requested program-related information to the Department of Labrador Affairs. SignatureTo sign your name, use your finger, mouse or other compatible input device inside the dotted box. To start signing, press or click, hold and move. To stop signing, lift or release. To clear the signature, press or click the arrows icon in the bottom right corner.
