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Out-of-Province Travel Support Application Form

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

Who is eligible?


Applicant must have approval from Health PEI for out-of-province medical services.

Applicant must be a PEI resident and hold a valid PEI Personal Health Number.

Applicant must submit a current Canada Revenue Agency Notice of Assessment(s).

Applicants whose travel expenses are supported by other non-provincial government assistance will not be eligible for this program.

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 we define “Applicant”?


An applicant must be an adult (refer to definition below) and will be the person to whom all correspondence relating to this program will be sent.
How do we define “Adult”?


An adult is a person 18 years of age and over. Please note that for the purposes of the Out-of-Province Travel Support Program although an adult is anyone 18 years of age or over, Maritime Bus applies adult fares for children over the age of 12. Any travel subsidy approved through the Out-of-Province Travel Support Program will be applied to the applicable fares.
How do we define “Spouse”?


A spouse is a person who is your partner in a marriage or common-law union.
How do we define “Essential Escort”?


An eligible essential escort is either a) one parent/guardian or designate for a child less than 18 years of age; or b) a person who is required to accompany a patient for medically necessary reasons for safe patient transport.
How do we define “Household”?


A household is defined as the applicant and spouse.
How do we define “Household Income”?


Household income includes the income of both the applicant and spouse.
Is Maritime Bus wheel chair accessible?


Yes. Please indicate when booking tickets as Maritime Bus requires 72 hours notice if wheel chair accessibility is required.
How do I make a reservation with Maritime Bus?


Call 1-800-575-1807
Applicant


Surname: *
First Name: *
Initial: *
Personal Health Number: *
Date of Birth (yyyy-mm-dd):: *
Marital Status: *
Medical Reason: *
Is an essential escort requested?: *
Yes
No
Spouse (as applicable)


Surname:
First Name:
Initial:
Personal Health Number:
Date of Birth (yyyy-mm-dd):
Marital Status:
Applicant’s Mailing Address


Street/PO Box: *
City/Town: *
Province: *
Postal Code: *
Building/Apt Number:
Telephone Number: *
Mobile Number:
Email address:
If Patient is a Child


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


Copies of Canada Revenue Agency Notice of Assessment for the tax year immediately preceding the date of this application are required for both applicant and spouse in order to determine eligibility. Should more than 12 months elapse from the original application, updated 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: ooptravelsupport@gov.pe.ca.

Personal information on this form is collected under section 31(c) of Prince Edward Island’s 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.

Attach relevant supporting Canada Revenue Agency Notice of Assessment(s)


(more) relevant attachments:
(more) relevant attachments:
(more) relevant attachments:
(more) relevant attachments:
Declaration And Consent


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 PEI’s 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 acknowlegde you have read the Declaration And Consent above:: *

For further information


Website: www.healthpei.ca/ooptravelsupportprogram
Email: ooptravelsupport@gov.pe.ca
Telephone: (902) 368-5918

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