Forms and Policies

This form is used by practitioners and/or their billing staff to request an electronic user number, which is required in order to submit electronic claims for services rendered. The form also provides the option for the practitioner to request a listing of all patients and their demographic data that the practitioner has submitted claims for over the past two years. This form is applicable to all practitioners and/or their staff who submit fee-for-service claims for services rendered to Manitoba Health, Seniors and Active Living. This form is processed by Manitoba Health, Seniors and Active Living.