Essential Medical Travel Assistance Program Application

Review the Essential Medical Travel Assistance Program page for eligibility, availability, required information, and contact details before completing this form.

MNBC Essential Medical Travel Assistance Program (EMTAP) Application

The Essential Medical Travel Assistance Program (EMTAP) is a program that provides pre-approved funding and reimbursement to eligible Métis Citizens so they can travel to essential medical appointments, procedures, specialists, etc., which are unavailable in their local community. MNBC works with you to provide reimbursement for travel to your medically necessary appointments or as a pre-approval if you are struggling to pay for the cost of travel to your health service

Eligibility

Do you fit within our Income Thresholds based on Line 2600 of your Notice of Assessment (NOA)?(Required)

Individuals with a single income of $27,352 or less.
Couples with a combined income of $38,682 or less.
Families/Households composed of 3 individuals with a combined income of $47,375 or less.
Families/Households composed of 4 individuals with a combined income of $54,704 or less.

Yes

Notice of Assessment Uploaded(Required)

Unsure where to find your Notice of Assessment? Visit this link: https://www.canada.ca/en/revenue-agency/services/tax/individuals/topics/about-your-tax-return/a-copy-your-notice-assessment-reassessment.html

Accepted file types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip, Max. file size: 50 MB.

If your financial status has significantly changed due to a medical reason over the last year and it is not reflected in your NOA, you may still qualify for the EMTAP program. This will be reviewed on a case-by-case basis. If this is the case, please provide a brief description below:

f you are ineligible for EMTAP under Question 1, but applying due to a medical reason as described in Question 3, please upload BOTH of the following documents to represent the change in your medical and financial status.

6 months of banking statements which reflect your change in income due to a medical reason

Applicant Information

Name

First Name Last Name

Prefered Name

Date of Birth(Required)

Age Group(Required)

0-15

16-29

30-64

65+

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City Province Postal Code

Are you a registered Citizen with MNBC?(Required)

If no, please re-apply once you receive your MNBC Citizenship number.

Yes

MNBC Citizenship Number(Required)

Have you participated in EMTAP in the past?(Required)

If yes, there is a limit to the amount of funds an individual, couple or family can request for each fiscal quarter. This may impact your ability for full coverage or coverage for this quarter.

Yes

Unsure

Region(Required)

Gender(Required)

Man

Woman

Two-Spirited

Gender-Fluid

Gender Non-Conforming

Non-binary

Prefer not to say

Gender not represented (Please specify in other)

Other

Are you applying on behalf of yourself, yourself and a travel companion, or an MNBC Citizen requiring assistance in applying (e.g. a minor).(Required)

Myself

Myself and a travel companion (See the EMTAP Travel Companion Form)

On behalf of an MNBC Citizen requiring assistance (See the EMTAP Travel Companion Form)

If you are require a medical or non-medical travel companion, or if you are applying on behalf of an MNBC Citizen requiring assistance, please upload a completed EMTAP Travel Companion Form here:

Medically Necessary Health Service(Required)

Please select one of the following options

Medical services insured through the BC Medical Service Plan (MSP)

Publicly funded diagnostic tests and preventative screening programs

Treatment at the nearest appropriate facility in BC funded by or referred to by the National

Diagnostic tests and Psychological Assessments for educational purposes, such as hearing, vision, or developmental tests for children required by the school.

Medical supplies and equipment and vision care benefits where a fitting is required, and these fittings cannot be made in the community of residence.

Traditional Healers *Case-by-case scenario

Other

Please select one of the following options(Required)

Please upload a photo/screenshot of your health professional’s service request (e.g. Doctor’s Note) or a completed EMTAP Confirmation of Appointment Form

This Medical Appointment is the closest geographically to applicants home address that can provide appropriate medical care needed.(Required)

Health professional is the closest geographically to your home address that can provide the service the applicant is receiving. In most circumstances, this would be travel within the health authority the applicant resides in.

Yes

Other

All Options for Private Insurance has been utilized(Required)

Yes

Other

All Options for Public Social Programs (E.g. Hope Air) has been utilized(Required)

Yes

Other

Are you okay working with MNBC to ensure all Public Social Programs have been accessed/applied for prior to EMTAP approval?(Required)

Yes

Are you aware of other MNBC Social Programs (MESAP, MCC, RHC Program)?(Required)

Yes

If no, would you like MNBC to provide you with more information?

Request is a One-Time service or Reoccurring?(Required)

One-Time Service

Reoccurring

Date of Medically Necessary Health Service(Required)

Date Leaving Home Address to attend Medically Necessary Health Service(Required)

Time Leaving Home Address to attend Medically Necessary Health Service(Required)

Date Returning Home Address to attend Medically Necessary Health Service

Time Returning Home Address to attend Medically Necessary Health Service(Required)

Request for Reimbursement or Pre-Approval(Required)

Note: Pre-Approval requires a minimum of 5 business days for approval and additional documents are required

Reimbursement

Pre-Approval

Proof of Travel- Transportation(Required)

Please upload screenshots/photos of your travel route (eg. Google Maps), receipts for Travel (eg. Ferry tickets/flight tickets)

Proof of Travel- Accommodation

Please upload screenshots/photos of your travel route (eg. Google Maps), receipts for Travel (eg. Ferry tickets/flight tickets)

Void Cheque(Required)

Please upload a void cheque for fund transfe

Declaration of Truth(Required)

The applicant declares that all the information given in this application form is true and complete.
The applicant declares that the notice of assessment is factual and true.
The Métis Citizen applicant(s) declares that they have not applied for First Nation status under Bill C31, Bill C-3, or Bill S-3 or any other government legislation. The MNBC Central Registry Office will periodically verify that grant recipients maintain MNBC Citizenship.
The applicant acknowledges and agrees that the facts given in this application form will be kept and disposed of as required by the Information Management Act.
The applicant agrees that MNBC may collect data and contact them from time to time for the purpose of conducting any participant-related surveys or program information
The applicant(s) understands that this application does not obligate MNBC to approve funding.
All applicants who give personal information to MNBC shall be required to consent to the release of that information to MNBC to comply with the BC Personal Information Protection Act (PIPA) and Freedom of Information and Protection of Privacy Act (FIPPA).

Consent

The applicant(s) gives consent to MNBC and its agents to investigate and disclose any of the information given in this application form for internal purposes or to other agencies for any of the following reasons:
To confirm household income;
To confirm eligibility for the program;
Audit purposes; and/or
Referral to other programs within MNBC or outside service providers. The applicant(s) consents to release the

Information provided in this application to MNBC, and understands this information will be used in accordance with the BC Personal Information Protection Act (PIPA) and Freedom of Information and Protection of Privacy Act (FIPPA).

By Checking this Box and submitting your application you agree to the above declaration of Truth and Consent

I consent