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NB Medicare Request for Prior Approval (35-5161)

New Brunswick physicians use this bilingual 2-page form to ask Medicare, before treatment, whether a proposed service that could be considered cosmetic will be insured. It captures the service code and units, diagnosis, deformity and functional impairment, and whether the patient or a third party will pay part of the cost. Medicare records its decision in a box on the form.

Who completes it

The physician who will perform the service completes and signs everything except the New Brunswick Medicare Decision box, and identifies the referring practitioner by name and number. Medicare completes and signs the decision section.

Submitting and payment

How to submit it
Mail the completed form to Health, Medicare, at the address printed on the form, before the service is provided.

Good to know

  • If Medicare decides the service is not insured, related services such as anaesthesia, surgical assist and hospital care are not covered by Medicare or provincial hospital services either.
  • If any part could be described as cosmetic, the form asks you to state the medical requirement and whether the patient or a third party will pay toward the cost.
  • Rate the deformity as mild (noticeable), moderate (very noticeable) or severe (unsightly), and rate functional impairment separately as mild, moderate or severe.
  • Related history is classed as congenital, acquired, trauma or developmental, and the Remarks box is for additional factors, including extenuating circumstances that may affect the decision.

Get the official form

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

Request for Prior Approval - Medicare

Demande d'approbation préalable - Assurance-maladie

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it 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

When should a New Brunswick physician request prior approval from Medicare?

When a proposed service might not be insured, particularly when any part of it could be described as cosmetic and the patient is asking for Medicare coverage. The form lets Medicare decide in advance whether the service, identified by service code and requested units, is approved as an insured service.

Is the NB Medicare prior approval form available in French?

Yes. Form 35-5161 is bilingual, with every label in English and French, and its French title is Demande d'approbation préalable - Assurance-maladie. The version in use carries the revision date 5/13 and runs 2 pages, with the Medicare decision section at the end of page 2.

What happens if Medicare decides the service isn't insured?

Medicare marks the decision box as not an insured service under New Brunswick Medicare. The note beside that box warns that related services, such as anaesthesia, surgical assist and hospital care, are then not covered by Medicare or by the province's hospital services. An approval confirms the service as insured.