MTAP In-Province Flight Pass Application 1General Information2Section 1: Applicant Information3Section 2: Escort information4Section 3: Details of Medical Travel5Section 4: Supporting Documentation6Section 5: Declaration General InformationThe In-Province Flight Pass is available to Labrador–Grenfell Health Zone residents travelling in-province for specialized insured medical services. 1. What the In-Province Flight Pass Pays (April 1 to March 31) Covers 75% or more of approved airfare for the patient and approved escort (if needed) The first trip each year may be covered up to 100% (up to $1,000 total) Coverage for later trips is 75% or 85%, based on total yearly airfare costs (including eligible escort travel) 2. First Trip Each Year Up to $1,000 in total airfare is prepaid in full for the patient and approved escort If airfare is higher, MTAP pays $1,000 plus 75% of the remaining cost (for both, if needed) 3. Additional Trips in the Same Year 75% coverage if total yearly airfare is $1,001–$8,000 85% coverage if total yearly airfare is over $8,000 Total yearly airfare includes approved escort travel 4. Important Rules You can get up to 3 Flight Passes for 3 separate trips within a 6-month period. If an escort is approved, they may also get a pass for the same trips. These escort passes do not count toward the 3-trip limit. After 3 passes, you must submit a post-travel claim before getting another pass. You must submit your claim within 6 months after your trip. A guide to completing this online form can be found here. Getting Started 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) If needed, your escort's information (including their date of birth and supporting medical note) Documentation about your upcoming appointment (such as a confirmation) What to Expect After You Submit the Form MTAP staff will review your application. You will receive an email with the decision. Section 1: Applicant InformationProvide the information of the applicant traveling for the medical appointment.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 #.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(Required) Do you have private health insurance through your employer or an insurance plan you purchased yourselves (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 post-travel claim to the Department. Check with your insurer before travel to confirm their claim documentation requirements.If Yes, Name of Insurance Provider: Are you eligible to receive travel support for this trip from another department, organization, employer, or government, including the Non‑Insured Health Benefits program (NIHB)?(Required) Yes No Are you 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 2: Escort informationProvide the information of the escort, if applicable. An escort must be medically required and supported by medical documentation from a physician. Do you require an escort?(Required) Yes No Escort Name First Last Escort Date of Birth Year Month Day Relation to Patient: Parent Spouse Other Other: Section 3: Details of Medical TravelPlease complete applicable sections below and note the required supporting documentation.Appointment Location(Required) Primary Reason for Travel(Required)Addiction Treatment FacilityCancer TreatmentDialysisFollow-Up Post SurgeryMammogramNuclear Medicine Test (MRI, CT, PET, etc.)Specialist Physician ConsultationSurgical DentalUltrasoundOtherDate of Appointment(Required) Year Month Day Physician Specialty(Required) If unknown or the appointment is only for specialized testing please indicate "Unknown" or "Testing"Patient is Departing From(Required)Churchill FallsDeer LakeGanderHappy Valley-Goose BayLourdes-de-Blanc-SablonSt. AnthonySt. John'sWabushPatient is Arriving In(Required)Churchill FallsDeer LakeGanderHappy Valley-Goose BayLourdes-de-Blanc-SablonSt. AnthonySt. John'sWabushEscort is Departing From(Required)Churchill FallsDeer LakeGanderHappy Valley-Goose BayLourdes-de-Blanc-SablonSt. AnthonySt. John'sWabushEscort is Arriving In(Required)Churchill FallsDeer LakeGanderHappy Valley-Goose BayLourdes-de-Blanc-SablonSt. AnthonySt. John'sWabushDo you require a round-trip ticket?(Required) Yes No Does your escort require a round-trip ticket?(Required) Yes No 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 Appointment Medical Support for Escort Other Supporting Documents Select All Section 5: Declaration of Eligibility for Medical Transportation AssistanceThe below declaration must be signed before processing of the application can occur. Unsigned applications will be considered incomplete and will not begin the review process. Privacy statement(Required) I agree to the privacy statement.• I declare that the information provided on this application 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 understand and agree that a post travel claim for assistance received through an in province flight pass application must be submitted within six (6) months of the eligible insured specialized medical service; that flight passes are limited to three consecutive trips within a six (6) month period unless a related claim is submitted; that failure to submit a post travel claim may restrict eligibility for future flight passes; and that failure to submit a post travel claim within twelve (12) months may result in recovery of assistance by the Department of Labrador Affairs. • 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 understand that if I have private health insurance benefits, medical travel expenses must be assessed by the private insurance provider before submitting my required post-travel 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 authorize the Department of Labrador Affairs to contact and share information with any other parties identified in this application for the purpose of verifying medical services received, and for auditing purposes. • 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, Workplace NL, NL Health Services, or any other funding received from an Agency, Board, Commission, organization (e.g. Hope Air) or Provincial/Federal Government or program, including the Non-Insured Health Benefits Program. • 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. • I authorize the Department of Labrador Affairs to disclose my personal information to third parties to verify eligibility for reduced cost air travel under the Medical Transportation Assistance Program (MTAP), including my name, address, and date of birth; the name and date of birth of any approved escort (if applicable); travel authorization details (number, trip type, destinations, and issue/expiry dates) for myself and any escort; and MTAP subsidy information, and I acknowledge that such third parties may provide the Department with information on flights booked, associated costs, and tickets that are cancelled, changed, transferred, or unused.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.
