The D&R Application

1. Member Statement

The Member Statement includes 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. This information assists HEB Manitoba to assess your claim. Please complete all questions in the Member Statement and then review, sign, and date the form. Please note that we can only accept original completed claim forms.

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 personal cheque. 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

• A completed direct deposit form. You can download a direct deposit form from your financial institution’s website via online banking or go to your financial institution for a copy. The document must include the financial institution number, branch transit number and account number. 

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 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.

2. Physician's Statement

The Physician’s Statement may be completed by a:

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

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 review and sign Section 1: Patient Authorization on page 1 of the Physician’s Statement. Signing here 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 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.