The D&R Application

1. Member Statement

The Member Statement asks questions about your demographic information, your job, your disability and/or medical conditions, and any income and/or benefits you may be eligible to receive. The requested information is needed to assess your claim. Please complete all questions in the Member Statement and ensure you review, sign, and date the form. Only original completed claim forms can be accepted.

Other Required Documents:

Authorizations

HEB Manitoba needs your authorization to collect the information necessary to assess and manage your claim for D&R Benefits. When you sign the authorization forms included with your application, HEB Manitoba can request the necessary information from your Physician, your Employer, and other relevant sources. For more information about your privacy, please see the information in the Privacy section of this website.

Electronic Funds Transfer Form

If your claim is accepted, D&R Benefits are paid by direct deposit through your financial institution into an account in your name. To identify the account and to confirm that it is your personal account, you must provide one of the following:

  • A void cheque for the account that you would like your D&R Benefits transferred into. To void a cheque, simply draw a line across one of your cheques and print the word “void” on it. Your name must be on the cheque, or you must provide documentation from your financial institution, on their letterhead, confirming that the account is in your name

OR

  • Documentation from your financial institution, on their letterhead, confirming the financial institution number, branch transit number, and account number for the account you would like your D&R Benefits transferred into. The document must confirm that the account is in your name.

Note: As D&R Benefits must be provided to the claimant, the account that you identify for HEB Manitoba to deposit your D&R Benefits into must be in your name. D&R Benefits are not assignable.

Proof of Age

To confirm your age, provide a photocopy of one of the following documents:

  • Birth certificate
  • Baptismal certificate
  • Canadian passport, or
  • Certificate of Canadian citizenship.

Updated Resumé

Provide an updated copy of your resumé, if available.

2. Attending Physician's Statement

The Attending Physician’s Statement may be completed by a:

  • Licensed medical Physician
  • Clinical psychologist with a doctoral degree in psychology whose primary professional activity is treating patients
  • Registered Nurse (Extended Practice)
  • Nurse Practitioner, or
  • Medical Specialist.

Note: The professional who completes the Attending Physician’s Statement must be providing care and treatment for your claimed medical condition, must be legally qualified and lawfully entitled to practice according to the laws of Manitoba, and cannot be related to you by blood or marriage.

Please supply your Physician with a signed Patient Authorization/Confidentiality Agreement Form (enclosed with your application), which will allow your Physician to provide the necessary medical information to HEB Manitoba. Please ensure that your Physician submits the completed original form prior to the application deadline.

You are responsible for providing medical evidence to prove that you are eligible to receive D&R Benefits. If the forms are not fully completed, your claim assessment will be delayed, and your eligibility for Benefits may be affected.

If your Physician charges to complete the Attending Physician’s Statement, you are responsible for paying the fee.

3. Employer Statement

Your Employer will complete this form to provide information regarding your last day worked, the physical and psychological demands of your job, and other information needed to assess your claim.

To assist you, HEB Manitoba will send the Employer Statement directly to your Employer for completion.

Your Employer will provide a copy of your job description, and HEB Manitoba will follow up with your Employer regarding the Employer Statement and job description. However, you are responsible for ensuring the Employer Statement is received by HEB Manitoba.

© 2017 HEB Manitoba

 

Disclaimer - This website provides a basic overview of the Healthcare Employees' Pension Plan (HEPP) and the Healthcare Employees' Benefits Plan (HEBP) (collectively the HEB Manitoba Pension and Benefit Plans). Not all employers participate in all Plans. Please check your eligibility for benefits with your employer.

HEB Manitoba is a name notation registered by the Healthcare Employees’ Pension Plan – Manitoba and the Healthcare Employees’ Benefits Plan – Manitoba and under which each of their respective undertakings is carried out.

The information on this website is for convenience of reference only and has no official sanction. View our full disclaimer here.