Medical

Newsroom
Announcements
Events
Job Postings
Media Releases

Medical Travel Assistance Program Intake Form

"*" indicates required fields

Section 1

This program is available to citizens registered with Metis Nation-Saskatchewan
Please note, abuse of the program and/or staff harassment may result in refusal from the program.

First Name*

Middle initial

Last Name*

Are you a citizen from the Métis Nation–Saskatchewan?*

Yes

Relation to citizen - I am…

MN–S Citizenship Number (or your immediate family member)*

Sorry, you have to be a citizen or an immediate family member of a citizen from the Métis Nation–Saskatchewan to proceed.
Apply for MN-S Citizenship

Street*

City*

Postal Code*

Phone*

Email Address*

Emergency Contact Information Name

Emergency Contact Phone Number

Relation to Family Member

Section 2

What will you be using the Medical Travel Assistance Program for?

Primary care appointment (e.g., vision, dental, family doctor)

Non-primary care appointment (e.g., referral, specialist, prenatal)

Vaccine / Immunization (eg Flu, COVID, HPV, etc.)

For your medical travel, which will you be needing assistance for?

Accommodations

Gas/Parking

Healthy Food Allowance

Do you want MN–S to book your hotel?

Yes

Destination City*

Check-in date*

MM slash DD slash YYYY

Check-out date*

MM slash DD slash YYYY

Consent*

I agree to the Hotel Liability Policy

I agree to abide by all hotel rules and regulations provided by the hotel set forth at the time of check in. I acknowledge that I may be liable for any incidental costs and damages I have caused or by any persons staying or visiting with me. Should any invoice following my stay be received by MN–S,
I acknowledge that I may be responsible for the charges incurred including incidentals (telephone, food, beverage, TV rentals, etc.) and other charges or damages, with the potential of limitations or suspension from future MN–S Medical Travel Assistance Program support.
I acknowledge that if I do not check in on the requested date without sufficient notice, I may also be responsible for the incurred no-show fee. MN–S must be notified with at least 48-hours’ notice of cancellation to avoid a no-show fee.
By providing my consent, I acknowledge I will adhere to the responsibilities and requirements brought forward by MN–S Ministry of Health for hotel accommodations booked on my behalf.

Section 3

Do you have any additional medical conditions that the program administrator should be aware of?

Yes

Please explain

Physician Name

Physician Phone Number

Appointment Location

Please attach documentation of your appointment with this form*

Drop files here or

Max. file size: 30 MB.

NOTE: To receive reimbursement, you will also need to submit Confirmation of Attendance from your doctor after your appointment.

Section 4

We use the following information to calculate fuel costs. 20¢ per KM

Where are you travelling from?

Where are you travelling to?

Household Income*

Please select your yearly household income before tax. Reimbursement will be prioritized for those citizens with high needs and low income

Under $40,000

$40,000 - $80,000

$80,000 +

How many dependents live with you in your home (e.g. children under the age of 18, sick, disabled or elderly requiring care)?**

Are you applying on behalf of a child/minor?

Yes

First Name

Middle Initial

Last Name

Birth Date

MM slash DD slash YYYY

Is the child/minor a citizen from the Métis Nation–Saskatchewan?*

Yes

Citizenship Number*

Please provide us with any additional information we may need to serve you better.

Consent and Acknowledgment*

I acknowledge and consent to the following statement.

I understand that by submitting this intake form to the Métis Nation–Saskatchewan (“MN–S”) for enrollment into the Medical Travel Assistance Program (“the Program”), I am consenting to the collection and use of my personal information for the purposes of administering my application and participation in the Program. I understand that this information is necessary for the purposes of administering my application and participation in the Program. I understand that my consent to collection and use of my personal information is a condition to my acceptance into the Program.

I hereby waive any and all claims against the MN–S, its employees, directors, officers and agents relating to the personal information that I am authorizing the MN–S to collect and use in administering my application and enrollment to the Program.

I authorize MN–S to collection of my personal information provided in support of my application to enable the MN–S to assess my transportation needs and to enable MN–S to confirm my entitlement to participate in the Program and to administer my participation in the same. I make this solemn affirmation conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath.