Forms and Policies

This form is used by practitioners and/or their billing staff when making a change to an authorized user or terminating an authorized user in relation to the submission of claims through the Electronic Practitioners integrated Claims Submission platform. This form identifies who is no longer an authorized user and identifies the new authorized user. 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.