MTAP Out-of-Province Medical Transportation Claim – Flights and Other Travel Costs

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 flights, hotels, or other travel costs for one out-of-province trip.

If you are claiming flights, hotels, or other travel costs for an in-province trip, 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)
If needed, your escort's information (including their date of birth and supporting medical note)
Documentation for your travel itinerary (i.e., flights)
Confirmation of attendance for each appointment
NL Specialist Referral Letter
Confirmation of any insurance provider's explanation of benefits (payout details) for travel
All expense receipts including proof of payment

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 Information

Provide the information of the claimant for this application. The claimant is the individual who will be receiving reimbursement.

Name(Required)

Phone Number(Required)

MCP Number(Required)

MCP Expiry Date(Required)

Date of Birth(Required)

Residential Address(Required)

Street Address Address Line 2 City / Town Province 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 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 Information

Please enter the information of each patient being claimed during this trip.

Is the claimant also a patient?(Required)

Yes

No

If yes, their information does not need to be entered below.

Patient Details

First Name

Last Name

MCP Number

MCP Expiry Date (YYYY/MM/DD)

Relationship to Claimant (e.g. Spouse/Child)

* 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

Amount

Is 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: Escort information

Provide the information of the escort, if applicable. An escort must be medically required and supported by medical documentation from a physician or nurse practitioner.

Do you require an escort?(Required)

Yes

No

Escort Name

Escort Date of Birth

Relation to Patient:

Parent

Spouse

Other

Other:

Section 4: Referring Specialist Physician

All out-of-province travel must be supported by referral from an in-province specialist.

NL Referring Physician Information(Required)

Phone Number

Clinic Address

Street Address Address Line 2 City / Town Province Postal Code

Name of Physician/Hospital to Whom This Patient Was Referred(Required)

Physician / Hospital Address of Where Patient Was Referred

Street Address Address Line 2 City / Town State / Province / Region Postal Code / ZIP Country

Section 5: Details of Medical Travel

Please complete applicable sections below and note the required supporting documentation.

Date of Departure(Required)

Primary Reason for Travel(Required)

Date of Return(Required)

Condition, Illness, or Physician Specialty(Required)

If unknown or the appointment is only for specialized testing please indicate "Unknown" or "Testing"

Appointment Details(Required)

Appointment Location

Date of Appointment (YYYY/MM/DD)

Name of Specialist

Use the plus sign to the right to add additional appointments.

Did either of the above appointments include an in-patient stay?(Required)

Yes

No

Date of Admission

Please include confirmation of the in-patient stay with your supporting documentation.

Date of Discharge

Expense Type

Airfare Date(s)

Airfare Amount

Expense Type

Taxi or Car Rental Date(s)

Taxi or Car Rental Amount

Expense Type

Paid Accom. Date(s)

Paid Accom. Amount

Expense Type

Private Accom. Date(s)

Private Accom. Amount

Expense Type

Ferries & Buses Date(s)

Ferries & Buses Amount

Total Expense Amount

Total Expense amount

Are you claiming private vehicle mileage for this trip?(Required)

Yes

No

Private Vehicle Mileage

Starting Location (e.g. City/Facility)

Ending Location (e.g. City/Facility)

Date(s) of Travel

Round Trip (Y/N)

Total Distance (Both Legs, if Round Trip)

Section 6: Supporting Documentation

Please upload all applicable supporting documentation.

Attach/Upload Documents

Drop files here or

Accepted file types: bmp, doc, docx, gif, heic, jpg, jpeg, pdf, png, tif, tiff

Maximum file size per form: 30 MB

Please confirm the following supporting documentation, if applicable, has been included with your claim

Travel Itinerary (i.e., flights)

Confirmation of Attendance for Each Appointment

Medical Support for Escort

NL Specialist Referral Letter

Confirmation of In-Patient Stay

Insurance Provider’s Explanation of Benefits (payout details) for Travel

All Expense Receipts Included

Completed the Supplier Form for Direct Deposit

Section 7: Declaration of Eligibility for Medical Transportation Assistance

The 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.

Signature

To 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.

Labrador AffairsMTAP Out-of-Province Medical Transportation Claim – Flights and Other Travel Costs

General Information

Getting Started

What to Expect After You Submit the Form

Section 1: Claimant Information

Section 2: Patient Information

Section 3: Escort information

Section 4: Referring Specialist Physician

Section 5: Details of Medical Travel

Section 6: Supporting Documentation

Section 7: Declaration of Eligibility for Medical Transportation Assistance

Labrador Affairs
MTAP Out-of-Province Medical Transportation Claim – Flights and Other Travel Costs