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Manitoba Medical Equipment Request and Justification

Manitoba's Disability and Health Supports Unit (DHSU) uses this form to request medically essential equipment and devices for people enrolled in Employment and Income Assistance, Manitoba Supports for Persons with Disabilities, Children's disABILITY Services or Community Living disABILITY Services. Standard items are picked from the Materials Distribution Agency (MDA) catalogue, while specialized equipment needs a therapist's justification. The stated aim is basic, cost-effective equipment.

Who completes it

Section 2 (prescriber) is completed only by a regulated health professional, and any regulated health professional may complete Section 3a for standard catalogue equipment. Section 3b (specialized equipment) is completed by an occupational, physical, respiratory or speech language therapist, and Section 1 is filled in on the client's behalf.

Submitting and payment

How to submit it
Send the completed request to DHSU Provincial Services electronically by email, or by fax or mail, as printed on the form. Justification letters for specialized equipment must be included in or attached to the form.
Who pays
No fee or billing code for the health professional appears on the form; approved equipment is provided as a support of the client's program and delivered through MDA.

Good to know

  • Section 3a lists standard items by MDA SAP number, quantity and product description, along with the diagnosis and how the condition affects daily functioning.
  • For Section 3b the form suggests covering assessment findings, home and functional status, current equipment and why it no longer works, product parameters, equipment trialled and expected outcomes.
  • Communication (AAC) devices are for Children's disABILITY Services clients only; the device must be the child's primary mode of communication, and home computers do not qualify.
  • Section 2 asks whether the client is pending hospital discharge, with the date, and Section 1 asks whether another plan, such as MPI, Blue Cross, WCB or FNIHB, covers the item.

Get the official form

Download the current version from the source each time; forms change without notice.

Medical Equipment Request and Justification

Official pagePDF

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.

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Frequently asked questions

Who can complete the Manitoba Medical Equipment Request and Justification form?

Any regulated health professional can complete Sections 2 and 3a for standard equipment from the MDA catalogue. Specialized requests in Section 3b, such as lift systems, tracking or ramps, must come from an occupational, physical, respiratory or speech language therapist, with a justification letter or report.

What should a specialized equipment justification include?

The form lists what DHSU looks for: what prompted the request, goals, relevant medical interventions and prognosis, whether a home assessment was done, functional, physical and cognitive status, the current equipment and its funding source, possible solutions with parameters, equipment trialled, and justification for any up charges beyond basic and essential.