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If you earned income directly or indirectly from Manitoba Health during the 2021 calendar year, complete this form to claim a partial rebate of the CMPA fees that you paid during that period. Your rebate will be prorated based on the number of months you practiced in Manitoba during that period.

Please answer the following questions so that Doctors Manitoba can calculate your rebate, then sign the authorization below.

You can find your Doctors Manitoba ID on the paper form that was sent to you.

PLEASE ANSWER ALL QUESTIONS

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Consent for collection, use and disclosure of personal information

I understand that it is necessary to provide personal information to Doctors Manitoba so they can determine my eligibility for the CME Rebate Program. I understand that personal information” includes, but is not limited to, my name, addresses, date/​location of birth, gender, other demographic information, bloc of practice, specialty, billing number(s), practice/​billing profiles, all contractual terms with, and financial compensation from, the Province of Manitoba (Manitoba Health and any other Department/​Agency), University of Manitoba, any Regional Health Authority, Workers Compensation Board, Manitoba Public Insurance and any other employer or contractor, including fee-for-service payments, salary and/​or contract payments, sessional payments, administrative and other stipends, on-call payments and other compensation and benefits.

I understand that this authorization will continue in full force until revoked by me in writing. I authorize Doctors Manitoba to access, collect, use and disclose my personal information for the following limited purposes:

  • To determine my eligibility for, and communicate with me (by mail, email, fax or phone) about, the Doctors Manitoba CME Rebate Program and any other program related thereto.
  • To maintain my personal information in the Doctors Manitoba database.·To develop and market Doctors Manitoba benefit programs, products and services tailored to the interests of physicians, residents/​interns, medical students and other eligible purchasers (e.g. family members).
  • To represent me and my professional interests, financial and otherwise, through advocacy, negotiation and arbitration.
  • To represent the professional interests, financial and otherwise, of physicians through advocacy, negotiation and arbitration.·
  • To communicate with me (via mail, text, email, fax or phone) about advocacy, negotiations and arbitration.