This form is used when there is no applicable tariff code listed in the Manitoba Physician's Manual for claiming medically required insured services. Physicians use this form to describe the procedure or treatment performed, providing the necessary information to assess their claim, such as the size of the lesion, the area involved, complications, etc. This form is applicable to physicians claiming a by report tariff for services not listed in the Manitoba Physician's Manual. This form is processed by the Claims Unit, Insured Benefits, Insurance Division.