Medical Newsroom Announcements Events Job Postings Media Releases Medical Travel Assistance Program Returning Citizens Intake Form "*" indicates required fields First Name* Middle Name Last Name* What will you be using the Medical Travel Assistance Pilot Program for?* Primary care appointment (e.g., vision, dental, family doctor) Non-primary care appointment (e.g., referral, specialist, prenatal) Cancer appointments: Dialysis appointments For your medical/treatment travel, which will you be needing assistance for? Accommodations Gas/Parking Healthy Food Allowance Patient Support Worker Do you want MN-S to book your hotel? Yes No Check-in date* MM slash DD slash YYYY Check-out date* MM slash DD slash YYYY Consent* I agree to the Hotel Liability PolicyI 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.Please upload documentation of your appointment* Drop files here or Select files Max. file size: 30 MB. NOTE: To receive reimbursement, you will also need to submit Confirmation of Attendance from your doctor after your appointment.