Attending physician's statement for a critical condition benefit application.
- Completed by
- Attending physician
- Issued by
- Manitoba Blue Cross
- Format
- Language
- English
Manitoba Blue Cross Assisted Care/Nursing Form
Manitoba Blue Cross uses this two-page recommendation form to support a claim for assisted care or private nursing services. It asks about any hospital stay or day surgery, the diagnosis, the level of care requested from RN to homemaker, the services and treatments provided and where care is received, and every section must be completed before it is returned to the Blue Cross Claims Department.
Who completes it
The attending physician or a nursing service completes questions 1 to 10, and the physician requesting services signs the form. If a nursing service completes it, written verification from the doctor must be attached, and the patient signs the authorization and consent on page 2.
Submitting and payment
- How to submit it
- All sections must be completed and the form returned to the Manitoba Blue Cross Claims Department; Manitoba Blue Cross lists it with its specialty claim forms.
Good to know
- The level of nursing care requested is ticked as RN, LPN, Health Care Aid or Homemaker.
- Question 9 asks whether the patient is a resident of a Personal Care Home.
- For hospital-related care, the form asks whether the stay was day surgery or an inpatient admission, with dates, the hospital's name and the reason for hospitalization.
- Question 10 asks for the name and address of the attending physician requesting the services, followed by the physician's signature and date.
Get the official form
Download the current version from the source each time; forms change without notice.
Assisted Care/Nursing Recommendation Form
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.
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
Can a nursing agency complete the Manitoba Blue Cross assisted care form?
Yes. The form may be completed by either the attending physician or a nursing service. If a nursing service completes it, written verification from the doctor must also be attached, and the attending physician requesting the services is named and signs at question 10.
What levels of care can be requested on the Manitoba Blue Cross form?
Question 6 lists four levels of nursing care: RN, LPN, Health Care Aid and Homemaker. The form then asks what services and treatments were or will be provided, where the nursing care was or will be received, and whether the patient lives in a Personal Care Home.
Where is the Manitoba Blue Cross assisted care form sent?
All sections must be completed and the form returned to the Blue Cross Claims Department. Manitoba Blue Cross lists it as the assisted care nursing recommendation claim form under its specialty claim forms, and the patient signs the authorization and consent on the second page.