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Manitoba Blue Cross APS: Critical Condition Benefit

Manitoba Blue Cross needs two forms for a critical condition benefit claim: the Application for Critical Condition Benefit, completed by the employer and claimant, and this one-page attending physician's statement. The physician records the diagnoses, onset and first treatment dates, medical history and prognosis, and how the condition affects activities of daily living. The statement goes to Case Management Services, which assesses the claim.

Who completes it

Part 2 is completed by the physician, or a nurse practitioner where applicable, who signs with their certified specialty and stamp. The patient completes and signs Part 1, the Patient Authorization, and the employer and claimant complete the separate Application for Critical Condition Benefit.

Submitting and payment

How to submit it
The form says to submit it directly to Manitoba Blue Cross Case Management Services and lists fax, email and mail as the channels.
Who pays
In the Part 1 authorization, the patient states they are responsible for any fees related to completing the form.

Good to know

  • Attach consultation, operative, hospital admission and discharge reports and test results including pathology; if test results are not attached, Manitoba Blue Cross will read this as tests not performed.
  • Do not send genetic test results: the form says not to provide them, and the patient's authorization excludes them from the information released.
  • For cardiac conditions, give the Canadian Cardiovascular Society classification where applicable, from Class 1, no limitation, to Class 4, complete limitations, and attach stress test or angiogram results.
  • You also indicate how eating, dressing, bathing, ambulation and toileting are affected, and whether you have concerns about the patient's ability to manage their own affairs.

Get the official form

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

Attending Physician’s Statement – Application for Critical Condition Benefit

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.

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

Frequently asked questions

Can a nurse practitioner complete the Manitoba Blue Cross critical condition statement?

Yes, where applicable. Part 2 is marked for completion by the physician or by a nurse practitioner where applicable. The person completing it prints their name and certified specialty, adds a stamp, address, phone and fax numbers, and signs and dates the statement.

What happens if test results are not attached?

Manitoba Blue Cross will interpret missing test results as tests that were not performed. The form asks for copies of all relevant consultation reports, operative reports, hospital admission and discharge reports, and test results or investigations including pathology reports, but not genetic test results.

What other form is needed for a Manitoba Blue Cross critical condition claim?

The Application for Critical Condition Benefit. Manitoba Blue Cross's forms page says two forms are required. The application has an employer's statement on coverage and work status and a claimant's statement for the employee, spouse or dependent, followed by an authorization and consent signed by the member.