Member Service Form

CHS-MC Member Service Claim
Please complete this form when requesting reimbursement and/or pre-approval of service expenses.

All services are subject to availability of monetary resources.

Please see Member Services for items that REQUIRE authorization from a member of the Manitoba Bleeding Disorders Program (MBDP) treatment team. If this policy applies to this request, please have the appropriate team member contact the Chapter.

PLEASE ALLOW 4 TO 6 WEEKS FOR PROCESSING

Please contact the Chapter office if you have any questions. 204.775.8625 or info@hemophiliamb.ca.
Full name*

First Name Last Name
Reimbursement requested for:

First Name Last Name
Address:*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone:*

Area Code Phone Number
E-mail:
Please describe the coverage you are asking for. Eg. Medical ID Jewelry
Receipts

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