Notice of Appeal Forms

NOTICE OF APPEAL FOR AUTHORIZED/RESIDENTIAL CHARGE APPEALS

This form should be completed for appeals related to review decisions made by Manitoba Health, Seniors and Active Living regarding the assessed daily rate charged to individuals residing in long-term care facilities (for example, hospitals, personal care homes).

NOTICE OF APPEAL FOR INSURED BENEFIT APPEALS

This form should be completed for appeals related to decisions made by Manitoba Health, Seniors and Active Living in relation to persons who are refused registration as an insured person or denied a benefit under The Health Services Insurance Act and regulations made under the Act (for example, out-of-province medical services, plastic surgery, travel subsidies).

GENERAL NOTICE OF APPEAL

This form should be completed for the following other types of appeals:

  • decisions made by a regional health authority assessment panel regarding an application for personal care in a personal care home;
  • decisions related to a request for approval to operate a laboratory or a specimen collection centre or the conditions imposed on an approval, or the revocation of an approval;
  • decisions related to licenses to operate a personal care home or the suspension or cancellation of licences;  
  • decisions made under The Emergency Medical Response and Stretcher Transportation Act related to licenses to operate an emergency medical response system or stretcher transportation service or the suspension or cancellation of licenses.

The following forms are available in Adobe Acrobat and MS-Word formats.

NAME OF FORM    
Notice of Appeal for Authorized/Residential Charge Appeals PDF MS-Word
Notice of Appeal for Insured Benefit Appeals PDF MS-Word
General Notice of Appeal
(for all other types of appeals other than Home Care appeals)
PDF MS-Word
Representative Authorization PDF MS-Word
Information Checklist (for Insured Benefit appeals) PDF MS-Word

arrowFor Notice of Appeal for Home Care appeals, see also: Home Care Appeal Forms