Medical Care Plan
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
Home
Provide duration of service:
YYYY MM DD
YYYY MM DD
Health and Community Services
OUT-OF-PROVINCE CLAIM
SECTION A PATIENT INFORMATION (To Be Completed By Patient or Parent/Guardian) – PLEASE PRINT CLEARLY
Patient Surname
ll Given Names MCP Number Card Expiry Date
Surname at Birth (if different from above) Date of Birth Sex
Male Female
Daytime Telephone Number Email Address
PERMANENT Mailing Address: Street / P.O. Box City / Town Province Postal Code
TEMPORARY Mailing Address: Street / P.O. Box City / Town Province / State Postal
/
Zip Code
Date of Departure Fr
om Home Place Where Treated (Province/Territory) Date of Arrival Is this a Permanent
Move?
Yes
No
Date of Return Home
Reason for Absence From Home:
Vacation
Business Study – Name of Institution __________________________________ Other – Specify ____________________
DECLARATION
I hereby declare, conscientiously believing it
to be true and knowing it to have the same effect as if it were made under oath and by virtue of
the Canada Evidence Act,
that the information
given above is correct and that
I am a beneficiary of
the Newfoundland & Labrador Medical Care Plan.
Signature of Patient (or parent/guardian, if
applicable):
_____________________________________________________________ Date:
__________________________________
Parent/guardian signature required if patient is less than 16 years of age. If signed by other than patient, please state relatio
nship to patient.
____________________________________
SECTION B PAYMENT INFORMATION
Payment should be made to: Treating physician Patient / contract holder Third party – Specify _______________________________________________________________
ddress of Third Party (if applicable): Street / P.O. Box City / Town Province / State Postal / Zip Code
SECTION C PHYSICIAN / TREATMENT INFORMATION (To Be Completed By Physician) - PLEASE PRINT CLEARLY
Physician Surname
ll Given Names Specialty
Certified
Non-Certified
Street / P.O. Box City / Town Province / State Postal / Zip Code
Name of Referring Physician
Services Provided In:
Office Hospital In-Patient Hospital Out-Patient
If Anesthetist Surgical Assist Psychiatrist Hours __________ Minutes __________
IF HOSPITAL SERVICES: Name of Hospital
dmission Date Discharge Date
Street / P.O. Box City / Town Province / State Postal / Zip Code
Procedure / Treatment Fee Code Fee Date of Service Duration For Office Use Only
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
Diagnosis and Other Remarks
Claim Involves:
Workers' Compensation Pensionable Disability
Automobile Accident Other Third Party
Physician's Signature
Date Language of
Correspondence
English French
PLEASE PROVIDE ORIGINAL DOCUMENTATION
PRIVACY NOTICE
Personal health information collected, used, disclosed, and safeguarded is in accordance with the Personal Health Information Act (PHIA). If you have any questions about the collection or use of this information please contact our office. The
Department of Health and Community Services privacy statement can be found at www.health.gov.nl.ca/health/PHIA.
Medical Care Plan
P.O. Box 5000, Grand Falls-Windsor, NL, Canada, A2A 2Y4
Telephone: (709)292-4000 Toll Free: 1-800-563-1557 Facsimile: (709)292-4053 http://www.gov.nl.ca/mcp
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