The Manitoba Health Appeal Board

Notice of Appeal for Authorized/Residential Charge Appeals

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Notice of Appeal for Authorized/‌Residential Charge Appeals

Appellant's Identifying Information

Last Name

First Name

Preferred Pronouns

Personal Health Identification Number (PHIN)

Manitoba Health Registration Number

Marital Status

Date of Birth

Facility's Information

Name of Facility

Facility Representative's Last Name

Facility Representative's First Name

Facility Representative's Title

Street Address

City/Town

Province

Postal Code

Phone Number

Fax Number

Email Address

Appellant's Representation on Appeal

Parties to a hearing have a right to attend the hearing and/or be represented by legal counsel or by another person who has the appropriate legal authority or who the parties have designated in writing as their representative or a support person. The Manitoba Health Appeal Board offers a referral service to Legal Aid Manitoba's Advocacy Unit, which operates out of the Public Interest Law Centre. The Advocacy Unit can review your appeal matter and assist you with an application for legal aid. If your application is accepted by Legal Aid Manitoba, your case will be referred to the Advocacy Unit, which is supervised by the Public Interest Law Centre. If you do not qualify for legal aid, the Advocacy Unit may be able to provide you with information and guidance on the issues you are dealing with.

Who will be representing you on this appeal? I will be representing myself on this appeal. I will be represented by legal counsel. I will be represented by another individual. I require assistance obtaining legal aid representation.

Legal Counsel's Information

Organization

Last Name of Legal Counsel

First Name of Legal Counsel

Preferred Pronouns

Street Address

City

Province

Postal Code

Telephone Number

Individual's Information

Last Name

First Name

Preferred Pronouns

Relationship to Appellant

Street address/P.O Box

City/Town/Municipality

Country

Province/State

Postal Code/Zip Code

Telephone Number

If this form is not completed by the Appellant (the person who the appeal is about) OR in the case of a minor child, the parent or legal guardian), the person signing on behalf of the appellant must provide a copy of their authority to do so [for example, an order of committeeship or substitute decision-maker, a grant of power-of-attorney that sets out sufficient authority for the person to act in these circumstances or a representative authorization form, which is available at the Board's office or on its website.

Manitoba Health Appeal Board
102 - 500 Portage Avenue
Winnipeg MB, R3C 3X1
T (204) 945-5408 Toll Free 1-866-744-3257 F (204) 948-2024
Website www.manitoba.ca/health/appealboard

Residential/‌Authorized (Daily Rate) Information

Facility Assessed Rate

Rate Year:

Daily authorized charge/rate:

Effective Date of Charge:

Manitoba Health Review Decision/Disposition

Review Number:

Date of Reviewed Decision:

Daily authorized charge/rate (assessed by Manitoba Health):

Documentation

Attach a copy of the written decision from Manitoba Health. Files must be in .jpg or .jpeg format and no larger than 3MB each in size.
If you have other documents you'd like to submit as part of your appeal, please send to appeals@gov.mb.ca.

Issue(s) Under Appeal

TAKE NOTICE that pursuant to the provisions of The Health Services Insurance Act and its regulations, I hereby provide notice of my appeal to the Manitoba Health Appeal Board against the above-noted review decision of Manitoba Health on the following grounds (reasons for appeal):

Request for Extension of Time to File Appeal

Pursuant to Section 10(2) of The Health Services Insurance Act, an appeal must be commenced by mailing or delivering a notice of appeal to the Manitoba Health Appeal Board not more than 30 days after the date the client and/or his/her representative received notice of the Disposition of the Review that was conducted by Manitoba Health, or within such further time as the Board permits. If this 30-day notice requirement was not met on this appeal, in order for the Board to determine whether it will permit an extension of the filing time, you must provide a detailed written explanation for the late-filed appeal request.

Declaration

By checking this box I certify that the information contained herein is true. 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.

Date