Newfoundland and Labrador's Medical Transportation Assistance Program publishes this one-page template so a physician can confirm, on letterhead, that a patient needs an escort to reach a specialized medical service. The note names the appointment, the condition and the patient's resulting limitations. MTAP considers escort costs only for medical reasons, and the patient attaches the note to their travel claim.
The physician writes and signs the whole note on physician or hospital letterhead. MTAP also accepts escort documentation from a nurse practitioner or an official appointment letter from the treatment provider, while the patient completes the MTAP claim itself.
Download the current version from the source each time; forms change without notice.
Physician's Sample Template (Non-medical Escort Note)
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.
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Yes. The MTAP Escort Guide says the documentation can come from a physician, a nurse practitioner, or an official appointment letter from the treatment provider. It must clearly state that an escort is required for medical reasons and support why. The posted template itself is written for physicians and placed on physician or hospital letterhead.
The template gives the patient's name, the specialist or treatment they are attending and the date if known, the specific medical condition, illness, injury or treatment, and what the patient is unable to do because of it, concluding that they need assistance to attend. It ends with the physician's name and signature.
Generally not when the patient is taken by medivac or road ambulance to and from an in-province facility and remains an inpatient for the whole stay, even if the escort travelled with them. That rule doesn't apply to patients under 18. For unexpected long hospital stays, MTAP may consider up to seven days of escort meals and lodging.