Medical Travel Application Form

Support Our Troops Medical Travel Application Form

All fields marked with an asterisk (*) are required. The French form can be accessed via the switch above.
- Personal information is collected by the Canadian Forces Morale and Welfare Services (CFMWS), under the authority of the National Defense Act, via a web-based application hosted by Jotform, a third-party company registered in Vancouver, British-Columbia.
  
  Personal information will be used to administer the Support Our Troops programs and to provide financial assistance. Your application is voluntary, however, if you choose not to provide your personal information, we may be unable to process your application and/or provide assistance. Personal information may also be used for marketing, program monitoring, evaluation, or reporting purposes, with the data being anonymized and aggregated whenever possible.
  
  Personal information is protected, and is only used and disclosed by CFMWS in accordance with the Privacy Act, as described in personal information bank CFMWS PPE 802 - Financial Assistance - Support Our Troops (SOT) Funds. Under the Act, individuals have rights of access to and correction of their personal information, and the right to file a complaint to the Privacy Commissioner of Canada regarding the institution’s handling of personal information.
  
  If you require clarification about this statement, contact the CFMWS privacy coordinator at ATIP.AIPRP@cfmws.com. For more information on the Privacy Act, consult the Office of the Privacy Commissioner of Canada. For the Jotform’s Privacy Policy, please visit their website at: Jotform Privacy Policy
- Section 1: Applicant's Information
- Name*
  
  First NameLast Name
- Service Number*
- Email*
  example@example.com
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Canadian Armed Forces (CAF) member's military element*
- Applicant's CAF community (closest Base or Wing)*
- Section 2: Medical Travel Details
- Name of Patient *
- Relationship to Member*
- Mileage (calculated by SOT using National Joint Council Low Kilometric Rates)Meals (Note: tips and alcohol are not eligible expenses)Long Term Parking (weekly/monthly) and/or toll FeesAccommodation (hotel, AirBnB, or emergency accomodations)Airfare (up to $500 per family) depending on the location and nature of the appointment
- Section 3: Claimed expenses
  
  Patient +1
- Amount Claimed for Meals*
  Tips and alcohol not included
- Amount Claimed for Accommodations*
- Amount Claimed for Long Term Parking and Toll Fees*
- Amount Claimed for Airfare*
- Other Amount Claimed*
  Please specify what the expense was in previous question
- Total Claimed Amount
- Section 4: Required documentation
  
  Required documents for application to be processed
- Required Documents:
  - MPRR
  - Doctor's note or medical recommendation/referral
  - Confirmation of appointment date(s)
  - Copy of detailed receipt(s) for applicable eligible expenses such as meals, long-term parking, tolls, accomodations and airfaire.
- Cancelof
- Please include a VOID cheque or banking information (Must be CAF member's or joint with CAF member)*
  
  Cancelof
- Section 5: Applicant Signature
- I hereby verify that all of the information I have provided with respect to my request for application for financial assistance from Support Our Troops, is true. This will also confirm that I consent to the collection, disclosure and sharing of personal financial information by SOT authorized personnel/SISIP Financial FCs/Chain of Command as deemed necessary for the sole purpose of assessing my request for this application, and for all other purposes associated with the administration of the Support Our Troops Funds and that no other use or disclosure of this information will occur without my consent, other than pursuant to the provisions of the Access to Information Act and Privacy Act.
- Signature*
  
  Clear
- Date of signature*
  
  DayMonthYear
Should be Empty:

Support Our Troops Medical Travel Application Form

Section 1: Applicant's Information

Section 2: Medical Travel Details

Section 3: Claimed expenses

Section 4: Required documentation

Section 5: Applicant Signature