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CanAssistance Trip Cancellation Physician Declaration

CanAssistance, which administers travel claims for Blue Cross and other travel plans, accepts this one-page declaration from the attending physician of the ill or injured person to support a trip cancellation, interruption or delayed-return claim. The physician gives the diagnosis, key dates and treatment history, and states whether the condition prevented travel and when they recommended cancelling the trip.

Who completes it

The attending physician of the ill or injured person completes the whole declaration and signs it with their specialty and stamp. The insured completes the separate cancellation claim form, online or on paper, and gathers the supporting travel documents.

Submitting and payment

How to submit it
The insured sends the signed claim form, this declaration and the other claim documents to CanAssistance through its secure upload site or by mail; the declaration also lists a fax option.
Who pays
The form states that any professional fees charged are the insured's responsibility.

Good to know

  • The declaration asks whether the condition is a complication of an underlying condition, whether the patient was hospitalized, and every visit or treatment date from the first consultation to the present.
  • If the patient is the person travelling, state whether the illness or injury made them unable to travel, the date you recommended cancelling and the dates they should not travel.
  • Manitoba Blue Cross's trip cancellation claim form, which is returned to CanAssistance, includes this declaration as its physician page.
  • The form also asks whether another doctor referred the patient, with the referral date and the referring doctor's name and address.

Get the official form

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

Attending Physician Declaration – Trip Cancellation

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.

See how Vero Documents works

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Who pays for the CanAssistance Attending Physician Declaration?

The insured. The form states that it is to be completed by the physician and that any professional fees charged are the insured's responsibility. The completed declaration is sent with the claim form and other supporting documents, such as the purchase invoice, e-tickets and proof of payment.

Does CanAssistance accept other medical documents instead?

Depending on the event, CanAssistance's cancellation claims page lists alternatives: a detailed medical report from the attending physician abroad that justifies interrupting or extending the trip, or documentary evidence such as a police report, death certificate, airline letter or damage report.

Which claim form goes with the physician declaration?

CanAssistance offers an online claim form or a PDF: the ANV Cancellation Form for coverage through group insurance or a travel insurer, and the ANV Cancellation Form Cardholder for credit card coverage, both dated 2024-10. The declaration's own edition is 01CAN0100A (2024-10).