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Manitoba Blue Cross Travel Attending Physician's Report

Manitoba Blue Cross's Travel Claims Department uses this one-page report from the attending physician to assess a trip cancellation claim. The physician gives the diagnosis, the first visit for the illness or injury that caused the cancellation, any hospital stay and the date until which the condition would preclude travel. Two questions ask whether the condition changed in the six months before the policy was bought and whether it then deteriorated.

Who completes it

The attending physician completes all sections of page 1 and signs with their address and the date. The patient signs the authorization and consent on page 2, and the claimant completes Manitoba Blue Cross's separate trip cancellation claim form.

Submitting and payment

How to submit it
The report is returned to Manitoba Blue Cross's Travel Claims Department at the mailing address printed on the form.
Who pays
Any charge for completing the form is the responsibility of the individual claiming the benefit.

Good to know

  • Question 6 asks whether the condition changed during the six months immediately before the policy purchase date; question 8 asks whether it then deteriorated to the point that the trip was cancelled.
  • Give the date until which, to the best of your knowledge, the condition would preclude travel, plus hospital admission and discharge dates if applicable.
  • This report is edition MBC-1017 (June 2008); Manitoba Blue Cross's current trip cancellation claim form, sent to CanAssistance, carries CanAssistance's Attending Physician Declaration as its physician page.
  • The form asks for a primary and a secondary diagnosis of the present condition, with the policy number and claim number at the top.

Get the official form

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

Attending Physicians Report

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 pays for the Manitoba Blue Cross Attending Physician's Report?

The person claiming the benefit. A note at the bottom of the report states that if there is a charge for completing the form, it is the responsibility of the individual claiming the benefit. The patient also signs an authorization and consent on page 2.

What does the report ask about the patient's condition before the trip?

Question 6 asks whether there was any change in the condition during the six months immediately before the date the policy was purchased. Question 8 asks whether, in your opinion, the condition deteriorated after that date to the point that the trip was cancelled, and question 7 leaves room for remarks.

Is there a newer physician form for Manitoba Blue Cross trip cancellation?

Manitoba Blue Cross's current trip cancellation claim form, edition 01CAB0096A (2022-08), is sent to CanAssistance and includes CanAssistance's Attending Physician Declaration for trip cancellation as its physician page. This report is an older Manitoba Blue Cross form, edition MBC-1017, dated June 2008.