Métis Nation of Ontario - Region 2 - Superior North Shore Métis Medical Support Program

Superior North Shores Métis Council is pleased to offer a Health Benefit Support Program to assist eligible citizens with Health related expenses. Funding is limited and on a first-come first-serve basis while funds remain available. Reimbursement amounts, eligible services, and program guidelines are subject to the Health Benefits Support Program Terms of Reference and may be amended by council at any time.

Before Submitting a request, please ensure you:

*Create a profile and ensure you have completely filled out this form in full

*Upload all required and supporting receipts and documentation

Greenstone Métis Community Health Support Form

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First name *

Last name *

Email *

Mobile

Gender *

Date of birth *

Address *

City *

Country *

State/Province *

Zip/Postal code *

MNO Citizenship Number *

Which Type of Medical Expense is this? (Cosmetic expenses are not eligible unless approved as a special request based on medical necessity) *

Special Request Information

Do you have other benefits? (ex: ODSP, CPP, Ontario Works, Trillium etc.) *

Yes No Partially Covered - balance remaining

Have you received support from other organizations or agencies ? if yes, please provide the forms with the name of organization or agency, Name of the contact and amount received.

if you have not accessed support from other organizations or agencies, why?

Upload Documents here (invoices and receipts)

Upload documents (Excel, Word, PowerPoint, PDF) if needed

Total Health-related costs requested *

Additional Comments?

* Please note, Submission of this application form does not guarantee approval or reimbursement of the full amount requested. Reimbursement amounts, if approved may be less then the amount applied for and are subject to available funding, eligibility requirements, and program criteria.

Processing times may vary, and payment timelines cannot be guaranteed. Approved applications may take up to a month or longer to process and issue payment.

I consent to the collection and use of the information I provide for the administration of the Health Benefits Supports Program and to help guide the development of future community health supports *

Yes No