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 ONE: PRE-SCREENING QUESTIONS

Is the EMTAP applicant aware you are applying as their companion?

Yes

No

To the best of your ability, please indicate the legal or medical requirement(s) that result in the client being unable to travel alone:

Client is a minor.

Client requires alternative legal consent or decision-making.

Client requires assistance with activities of daily living, such as dressing, eating, and bathing.

Client faces a language barrier.

Client is to receive instruction on specific and essential home medical or nursing procedures that cannot be given to the client only.

Client is undergoing a medical procedure or has a medical condition that will result in the client requiring assistance during the trip (i.e. A client will receive outpatient sedation as part of a medical procedure).

Client is a pregnant woman whose trip is for childbirth, including being closer to care while awaiting childbirth.

Other, please describe:

SECTION TWO: APPLICANT INFORMATION

First Name:

Last Name:

Email:

Phone:

First and Last Name:

Email:

Phone:

Address:

Address 2:

City/Town:

State/Province:

ZIP/Postal Code:

Are you a registered Citizen with MNBC?

Yes

No

If Yes, please provide your MNBC Citizenship Number:

SECTION THREE: MEDICAL OR NON-MEDICAL TRAVEL COMPANION

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

Medical Travel Companion (Please move to SECTION 4)

Non-Medical Travel Companion (Please move to SECTION 5)

SECTION 4: MEDICAL TRAVEL COMPANION INFORMATION

Please briefly describe why monitoring or stabilization is mandatory or required during travel from a medical professional:

Healthcare Professional Name:

Healthcare Professional License #:

Healthcare Professional Signature:

SECTION 5: NON-MEDICAL TRAVEL COMPANION INFORMATION

Please briefly describe why an escort is requested during travel from a companion:

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.