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Manitoba Therapeutic Diet and Nutrition Supplement Form

Manitoba's Disability and Health Supports Unit (DHSU) uses this form to approve a therapeutic diet allowance or nutrition supplements for people enrolled in Employment and Income Assistance, Manitoba Supports for Persons with Disabilities, Children's disABILITY Services or Community Living disABILITY Services. The professional ticks qualifying diagnoses for standard adult diets, describes non-standard or pediatric diets, or prescribes supplements. Approvals run for no more than 12 months.

Who completes it

The form says it may be completed by registered dietitians, physicians, nurse practitioners, physician assistants, nurses or practical nurses, who sign as the regulated health professional. Page 1 also records the client's current height and weight and a previous documented weight with its date.

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 professional; the approved diet allowance or supplements are provided to the client through their program.

Good to know

  • Section 1 standard diets are for adults only; if several diagnoses are ticked, the diet with the highest associated amount is provided if appropriate.
  • Diabetes must be confirmed by a fasting plasma glucose test and celiac disease by biopsy or antibody testing, and the pre-dialysis renal diet applies when GFR is below 30.
  • For higher calorie needs, give the rationale in Section 2 using the Harris-Benedict equations as revised by Mifflin and St. Jeor (1990).
  • If supplements supply 50% or more of daily energy needs, the therapeutic diet allowance may be adjusted, and combining supplements with a diet request needs a stated rationale.

Get the official form

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

Therapeutic Diet and Nutrition Supplement Request and Justification Form

Official pagePDF

Fill it with Vero

Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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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 therapeutic diet form?

The form names registered dietitians, physicians, nurse practitioners, physician assistants, nurses and practical nurses. The professional signs, gives their title, name and contact details, and dates the request. DHSU's request page adds that all requests must be completed by a health professional.

How long does a Manitoba therapeutic diet approval last?

Each diet category and the supplement section have their own review field, counted in months, and the form notes the period must not exceed 12 months. Malignancy and chronic wounds or burns also need the date of diagnosis, stage and treatment plan in Section 2, and gestational diabetes needs the due date.

Does the Manitoba diet form cover children?

Yes, but not in Section 1, whose standard therapeutic diets are for adults only. Pediatric diets go in Section 2 with the diagnosis, rationale and medically appropriate diet, and Section 3 covers nutrition supplements and products for children and adults, including whether the Manitoba Home Nutrition Program is involved.