EMTAP Travel Companion Form

EMTAP Travel Companion Form

To be completed by the EMTAP Client’s planned travel companion MNBC’s EMTAP benefits for a Travel Companion may include transportation coverage, accommodations, and meals for medical or non-medical companions for clients travelling to access medically necessary services.

Section 1: Pre-Screening Questions

Is the EMTAP applicant aware you are applying as their companion?(Required)
To the best of your ability, please indicate the legal or medical requirement(s) that result in the client being unable to travel alone:(Required)

Section 2:Applicant Information

Name
Address(Required)
Gender(Required)

Are you a registered Citizen with MNBC?(Required)

Section 3: Medical or Non-Medical Travel Companion

Are you applying as a medical travel companion or non-medical travel Companion?(Required)

Section 4: Medical Travel Companion Information

Section 5: Non-Medical Travel Companion Information

Note: The applicant is responsible for their companion. Any pre-approval and reimbursement funds will be paid directly to the applicant, not the companion themselves. It is the applicant’s responsibility to distribute the funds to their companion.