Skip to Main Content
Bookmark and Share print small medium large 


Out-of-Province Travel Support Multiple Trips Application Form

Fields marked with a red star (*) are mandatory.

Who is eligible?

Applicant must have traveled to an out-of-province medical service, be eligible for Health PEIís Out-of-Province Travel Support Program, and be required to make a number of trips to complete their treatment
What support is available?

The same initial subsidy amount for tickets on Maritime Bus Company is available per trip for eligible applicants.

Total Annual Net Household Income Ranges

$0 - $35,000 -100% Bus Ticket Subsidy
$35,001 - $50,000 - 50% Bus Ticket Subsidy
Greater than $50,000 - 0% Bus Ticket Subsidy

How do I apply for multiple trips?

Complete and submit the Out-of-Province Travel Support Multiple Trips Application Form to receive prior approval for multiple trip subsidies on Maritime Bus.
How do I verify number of trips require?

You can request this information from your treating Physician.
How do I make a reservation with Maritime Bus?

Follow the same procedure you did with your first visit by scheduling your own tickets by calling Maritime Bus at 1-800-575-1807. Please be prepared to provide your notice of approval.

Surname: *
First Name: *
Initial: *
Personal Health Number: *
Date of Birth (yyyy-mm-dd): *
Marital Status: *
Is an essential escort requested?: *
I have been pre-approved and have traveled out-of-province for elective medical service where multiple trips are required?: *
Multiple Trips

Multiple trips are required to complete treatment?: *
The estimated number of trips over the next number of months is: *
Applicantís Mailing Address

Street/PO Box: *
City/Town: *
Province: *
Postal Code: *
Building/Apt Number:
Telephone Number: *
Mobile Number:
Email address:

If Patient is a Child

First Name:
Personal Health Number:
Date of Birth (yyyy-mm-dd):
Street/PO Box:
Apt Number:
Postal Code:
Telephone Number:
Please Note:

Health PEI reserves the right to validate with the treating Physician and/or facility the number of trips required for your out-of-province medical service, and by signing the declaration statement, you agree to this practice.

Should more than 12 months elapse from the original application, copies of your Canada Revenue Agency Notice of Assessment for the tax year immediately preceding the date of this application will be required for both the applicant and spouse (or partner cohabiting with applicants) in order to determine eligibility. Incomplete applications will be returned to applicant for re-submission of all required information. For further information on this program, please call (902) 368-5918 or email:

Personal information on this form is collected under section 31(c) of Prince Edward Islandís Freedom of Information and Protection of Privacy (FOIPP) Act as it relates directly to and is necessary for providing services under the Out-of-Province Travel Support Program. If you have any questions about this collection of personal information, you may contact the Privacy and Information Access Coordinator at (902) 368- 4942.

Declaration And Consent

I, We, the undersigned hereby permit Health PEI to validate my required number of visits with the treating Physician/and or Facility.

I, We, the undersigned, hereby certify that I/We am/are not eligible for nor currently receiving support for travel costs through any other program.

I/We, the undersigned, consent to Health PEI contacting other programs to verify my or our eligibility for this Out-of-Province Travel Support Program.

I, We, the undersigned, declare that the information provided on this application is true and correct to the best of my/our knowledge.

I/We, the undersigned, agree to notify Health PEIís Out-of-Province Travel Support Program regarding any changes to our household income, or any other factor which may affect my eligibility for subsidy.

I /We, the undersigned, consent to the Canada Revenue Agency providing Health PEI with information regarding my/our income/s for the tax year immediately preceding the date of this application, for the purposes of verifying my/our incomes and eligibility for the Out-of-Province Travel Support Program.

Check box to acknowledge you have read the Declaration And Consent above: *

For further information:

Telephone: (902) 368-5918

Do you want a copy of the form?

Please send me a simple text-only version of the information I submitted.
Please send me an Acrobat version of the form, with the information I've entered above filled in, that I can print and save.
Please send me both the text-only version and the PDF.
Important Note: Email is not, by its very nature, a secure medium; if you choose to have your form emailed to you, the information you entered will be transmitted over the public Internet to your email box.

Email to address:

Submit the Form

  • Key Code:
  • Enter Key Code: 

When you click here, the information you've entered above will be sent to the public servant responsible for receiving and processing this form. If you've opted to receive an Acrobat version of the form by email, you will receive this file shortly.
image banner of links Emergency Numbers Walk-in Clinics Compliments and Complaints Find a Family Doctor Health Card Pharmacare Wait Times
back to top