D&R Application Checklist

Note: All completed original D&R application forms (Member Statement, Attending Physician’s Statement, Employer Statement and other forms) must be submitted prior to HEB Manitoba assessing the eligibility of your claim. HEB Manitoba will accept completed original forms only. It is your responsibility to ensure that all three forms are completed and received by HEB Manitoba by the application deadline.Before you mail your application, please ensure that you have fully completed and signed all original forms. Please include the following original forms and supporting documents:

  • Member Statement
  • Patient Authorization Form (two copies – provide one signed form to your Physician with the Attending Physician’s Statement and the other to HEB Manitoba with your application)
  • Authorization Forms
  • Electronic Funds Transfer Form
  • Void cheque or, if you do not have a chequing account, documentation from your financial institution on their letterhead that indicates the account where funds are to be deposited
  • Proof of Age (a copy of one of the following: birth certificate, baptismal certificate, Canadian passport, or certificate of Canadian citizenship)
  • Attending Physician’s Statement (or ensure your Physician is submitting this form)
  • Clinical notes, consult reports and test results (if applicable) related to the claimed medical condition (or ensure your Physician is submitting these documents)
  • Copy of your updated resumé, if available, and
  • A letter of explanation if your application is submitted after the application deadline.

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