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MBC-1017

Attending Physician's Report, Travel Claims

This report reaches you when a patient cancels a trip covered by Manitoba Blue Cross because of their own or a family member's illness or injury. The claim depends on whether the condition was stable in the six months before the policy was bought and whether it got worse afterwards, so your answers to those two questions decide it.

At a glance

Checked October 2026

Form number
MBC-1017
Issued by
Manitoba Blue Cross
Where
Manitoba
Completed by
Attending physician
Format
Fillable PDF
Language
English

What the report is for

Manitoba Blue Cross trip cancellation coverage refunds non-refundable travel costs when an insured cause, such as a sudden illness or injury, forces a cancellation. When the cause is medical, Manitoba Blue Cross needs a report from the attending physician. The report is short, and most of it turns on timing: when the condition began, whether it changed in the six months before the policy was purchased, and whether it deteriorated afterwards to the point of cancellation.

The report goes with the trip cancellation claim form, which the patient completes. Manitoba Blue Cross’s current claim instructions also describe an Attending Physician’s Declaration within the trip cancellation claim form. If the patient brings that declaration, complete it instead.

Who completes it

The attending physician who treated the illness or injury completes and signs the report. That’s sometimes a family member’s physician, when their illness is what stopped the trip. The patient completes the separate trip cancellation claim form and sends both with the receipts and tickets.

How to fill in the report

Patient, diagnosis, and first visit

Enter the patient’s name, the policy and claim numbers if the patient has them, and the primary and secondary diagnoses. Give the date of the first visit for the illness or injury that caused the cancellation, and any hospital admission and discharge dates.

How long travel was precluded

Give the date until which, to the best of your knowledge, the condition would prevent travel. Check it against the trip dates the patient gives on the claim form.

The six-month question

The form asks whether there was any change in the condition in the six months immediately before a date, which is the date the policy was purchased. Ask the patient for that date and write it in the blank. Then answer yes or no from the chart. Check the record for that window before you answer, including medication changes, new symptoms, investigations, and referrals, and explain any in the remarks.

Deterioration and remarks

Answer whether, in your opinion, the condition deteriorated after the purchase date to the point that the trip was cancelled. Use the remarks for the timeline: when symptoms worsened, what you found, and when you advised against travel. Print your name and address, then sign and date.

Common reasons it’s delayed

  • The policy purchase date left blank in the six-month question.
  • No date until which travel was precluded.
  • A “yes” to a change in the six months with no explanation in the remarks.
  • The deterioration question left unanswered.
  • An unsigned or undated report.

Submitting and who pays

The patient sends the report with the trip cancellation claim form, tickets, invoices, and refund notices to CanAssistance, which processes travel claims for Manitoba Blue Cross, through its secure upload or by mail. The claim must be submitted within 90 days of the loss. Any charge for completing the report is the responsibility of the person claiming the benefit, so bill the patient.

Get the official form

Download the current version from Manitoba Blue Cross each time. Forms change without notice, and an old edition can be returned.

Official page ↗ PDF ↗

Medulla Forms

Fill MBC-1017 from the visit and the chart.

Upload the fillable PDF to your practice's forms once. Medulla fills it from the visit and the chart open in your EMR, leaves blank anything the record doesn't support, and opens the form for your review. When it's done, save it to the patient's chart in one click.

Free 1-month trial. No credit card required.

Sources for this guide

Questions

Questions we hear a lot.

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

The person claiming the benefit. The report states that if there's a charge for completing it, it's the responsibility of the individual claiming.

Is the report required for a trip cancellation claim?

Yes, when the cancellation is due to illness, injury, or death. Manitoba Blue Cross's trip cancellation claim form says the patient must submit a completed attending physician's report, and a death certificate if applicable.

How long does the patient have to submit the claim?

The trip cancellation claim form says the claim must be submitted within 90 days of the loss. Manitoba Blue Cross also says CanAssistance must be told of the cause within 48 hours.

Who processes Manitoba Blue Cross trip cancellation claims?

CanAssistance processes travel claims on behalf of Manitoba Blue Cross. The patient uploads the claim through CanAssistance's secure upload or mails it to CanAssistance Travel Claims in Montreal.

Is patient information secure?

Yes. Medulla has a SOC 2 Type II report from an independent auditor, is HIPAA, PIPEDA, and PHIPA compliant, and is built and hosted in Canada, so patient data stays in the country and never gets pasted into consumer AI tools. Everything is encrypted in transit and at rest. See how we protect patient data.

More questions? Browse help.medulla.ca.