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Manitoba Medical Supply Request and Justification

Manitoba's Disability and Health Supports Unit (DHSU) uses this two-page form to request medical supplies for people enrolled in Employment and Income Assistance, Manitoba Supports for Persons with Disabilities, Children's disABILITY Services or Community Living disABILITY Services. The prescriber describes the diagnosis and its impact and recommends supply types, and the request lists each item with quantity per day and size. DHSU aims to provide the most basic, cost-effective supplies that meet a medically essential need.

Who completes it

A regulated health professional completes Section 2: prescriber details, the diagnosis and its impact, and the supplies recommended. Section 1 (client information) is filled in on the client's behalf, office staff complete the office-use fields, and parents or guardians of Children's disABILITY Services clients need only complete the diagnosis and type-of-supply part.

Submitting and payment

How to submit it
Send the completed form to DHSU Provincial Services electronically by email, or by fax or mail, as printed on page 2.
Who pays
The form lists no fee or billing code for the health professional; approved supplies are provided as a support of the client's program.

Good to know

  • Section 3 lists each supply with a description, the number used per day and the size where relevant; DHSU staff add the MDA SAP number.
  • DHSU staff record the delivery method (courier, mail, client pickup or bus) and the order frequency: one-time, on-call or ongoing automatic orders with repeats and an expiry date.
  • Section 1 asks whether another public or private plan, such as a regional health authority, MPI, Blue Cross, WCB or FNIHB, already covers the supplies.
  • DHSU applies each partner program's policies and legislation to decide eligibility, so the request must name the program the client is enrolled in at the top of the form.

Get the official form

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

Medical Supply Request and Justification Form

Official pagePDF

Fill it with Vero

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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

Can a parent fill in the Manitoba medical supply request?

For Children's disABILITY Services clients, the form says parents or guardians need only complete the diagnosis and type-of-supply section, and the prescriber details in Section 2 are marked if applicable. For other requests, DHSU's request page says the form must be completed by a health professional.

Which health professionals can request medical supplies from DHSU?

DHSU's request page lists physicians, registered dietitians, registered physician assistants, registered nurse practitioners, licensed practical nurses, registered nurses, registered midwives, occupational therapists, physical therapists, respiratory therapists and speech language therapists. The professional signs Section 2 and gives their organization and contact details.