Forms & Resources

Pharmacare Application Form

All Manitobans over the age of 18 should apply for Manitoba Pharmacare coverage. Only one form is needed per family. We suggest selecting the one time enrollment option on the form. This form should be adjusted if your marital status changes. Income tax filing must be kept up to date in addition to sending in this form. Please click here to access the form.

Deductible Adjustment Form

If your family’s income has changed it may be beneficial to fill out this form. You will need income receipts to complete the appeal process. Please click here to access the form.

Flu-Shot & Provincial Vaccination Form

Going to the pharmacy for your flu shot or pneumococcal vaccine? Save time by filling out this form ahead of time! Fill out as much information as possible and bring down to the Dauphin Clinic Pharmacy. Flu Shots are always free for our customers! Please click here to access the form.

Consent to Release Health Information

Fill out this form if you need your prescription information sent to another party or if you need prescription financial information sent to an accounting firm. Please click here to access the form.

Third Party Manual Claim Forms

Do you need to send in your prescription receipts manually? Did you get a prescription filled and not have your plan information with you. Click on your plan provider to access the form you need.

Blue Cross (Click on the health benefits claim form)

Blue Cross National

Greenshield

Claim Secure

Chambers Group Insurance

Sun Life Insurance

Manulife