Manitoba Health

eTemporary Out-of-Province Vacation Request

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eTemporary Out-of-Province Vacation Request

Below is a summary of the changes you are requesting. Please review the changes to ensure it is accurate before submitting. If changes are required click the EDIT button to return to the form and make changes. When you have confirmed that the information in this summary is correct scroll to the bottom of the page and click the SUBMIT button to submit the form.

Note: Your application is not complete until you have received a confirmation number.

eTemporary Out-of-Province Vacation Request

Cardholder's Information

Registration Number:

Personal Health Identification Number (PHIN):

Primary Phone Number:

Email Address:

Last Name:

First Name:

Middle Name:

Sex:

Date of Birth:

Current Address

Apartment/Unit Number:

Street address/P.O Box:

City/Town/Municipality:

Province:

Postal Code:

Mailing Address

The Mailing Address is the same as the Current Address.

Apartment/Unit Number:

Street address/P.O Box:

City:

Province:

Postal Code:

Information regarding temporary absence from Province

Do you wish to receive a Temporary Out-of-Province Registration Certificate to ensure uninterrupted coverage during your stay outside the province (and limited coverage for out-of country medical and hospital service), or for third party insurance purposes?

Do you wish to apply for up to an additional 100-day supply of medications for out-of-country travel? (Absence must be outside Canada and greater than 100 days)

Do you have spouse/dependents who will be temporarily absent from Manitoba?

Last Name:

First Name:

Personal Health Identification Number:

Spouse/dependants requires up to an additional 100-day supply of medications for out of country travel.

Last Name:

First Name:

Personal Health Identification Number:

Spouse/dependants requires up to an additional 100-day supply of medications for out of country travel.

Last Name:

First Name:

Personal Health Identification Number:

Spouse/dependants requires up to an additional 100-day supply of medications for out of country travel.

Last Name:

First Name:

Personal Health Identification Number:

Spouse/dependants requires up to an additional 100-day supply of medications for out of country travel.

Last Name:

First Name:

Personal Health Identification Number:

Spouse/dependants requires up to an additional 100-day supply of medications for out of country travel.

Last Name:

First Name:

Personal Health Identification Number:

Spouse/dependants requires up to an additional 100-day supply of medications for out of country travel.

Last Name:

First Name:

Personal Health Identification Number:

Spouse/dependants requires up to an additional 100-day supply of medications for out of country travel.

Last Name:

First Name:

Personal Health Identification Number:

Spouse/dependants requires up to an additional 100-day supply of medications for out of country travel.

Last Name:

First Name:

Personal Health Identification Number:

Spouse/dependants requires up to an additional 100-day supply of medications for out of country travel.

Last Name:

First Name:

Personal Health Identification Number:

Spouse/dependants requires up to an additional 100-day supply of medications for out of country travel.

Temporary address outside Manitoba

Apartment/Unit Number:

Street address/P.O Box:

City/Town/Municipality:

Country:

Province/State:

Province/State:

Postal Code/Zip Code:

I (We) will be temporarily absent from Manitoba Effective:

I (We) will be returning to Manitoba Effective:

Form Completed By

Last Name:

First Name:

Date:

By checking this box, I certify that I am completing this form as the cardholder or on behalf of someone who appears on my MB Health Card or for whom I have Power of Attorney. Section 42 of the Health Services Insurance Act provides for a fine of up to $5000 for a person convicted of making false and misleading statements.

After you click SUBMIT you will be directed to a CAPTCHA page. Once the CAPTCHA is completed successfully you will receive a Confirmation number for your submission, which indicates our office has received your request. Please make note of this confirmation number to reference when contacting Manitoba Health.