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 services.

Eligibility

Do you fit within our Income Thresholds based on Line 2600 of your Notice of Assessment (NOA)?
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. 
One file only.
200 MB limit.
Allowed 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.
-6 months of banking statements which reflect your change in income due to a medical reason

-Proof of medical condition which has had an effect on your income (ex: Doctor’s note)
One file only.
200 MB limit.
Allowed 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.

Applicant Information

Age Group
Are you a registered Citizen with MNBC?

If no, please re-apply once you receive your MNBC Citizenship number. To learn how to apply for citizenship, please visit the following link here

Have you participated in EMTAP in the past?
  • 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.
Region
Gender
Please specify in 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).
(See the EMTAP Travel Companion Form)
(See the EMTAP Travel Companion Form)
One file only.
200 MB limit.
Allowed 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.
Medically Necessary Health Service
Please select one of the following options
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
 
One file only.
200 MB limit.
Allowed 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.
This Medical Appointment is the closest geographically to applicants home address that can provide appropriate medical care needed.
  • 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. 
All Options for Private Insurance has been utilized
All Options for Public Social Programs (E.g. Hope Air) has been utilized
Are you okay working with MNBC to ensure all Public Social Programs have been accessed/applied for prior to EMTAP approval?
Are you aware of other MNBC Social Programs (MESAP, MCC, RHC Program)?
Request is a One-Time service or Reoccurring?
Request for Reimbursement or Pre-Approval
Note: Pre-Approval requires a minimum of 5 business days for approval and additional documents are required
Please upload screenshots/photos of your travel route (eg. Google Maps), receipts for Travel (eg. Ferry tickets/flight tickets)
One file only.
200 MB limit.
Allowed 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.
Please upload screenshots/photos of your travel route (eg. Google Maps), receipts for Travel (eg. Ferry tickets/flight tickets)
One file only.
200 MB limit.
Allowed 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.
Please upload a void cheque for fund transfer
One file only.
200 MB limit.
Allowed 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.
Declaration of Truth
  • 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