Menu
MTA Request Draft

Section A

Medical travel has been approved for
Appointment Time

Section B & C

You/your dependent is approved for medical travel from HOME COMMUNITY to APPOINTMENT COMMUNITY on APPOINTMENT DATE(S) at APPOINTMENT TIME(S) at APPOINTMENT ADDRESS(ES) with X escorts.

If you have questions on date/time/location please follow up with your local health center or hospital.

Employees are responsible to discuss leave entitlements with their supervisor.
Should you have any inquiries on your leave entitlements please talk to your supervisor or send in an inquiry to the HR HelpDesk by either e-mailing HRHelpDesk@gov.nt.ca or calling toll free at 1-866-475-8162 and the appropriate specialist will respond.

 

 

Do you or your dependant(s) have medical travel benefits through another Employer?
*this will not be saved on WGT’s system, the answer will be emailed to the BO only
Is this a Workplace injury?
*this will not be saved on WGT’s system, the answer will be emailed to the BO only
Per the information we have on file you must arrive in APPOINTMENT COMMUNITY by ARRIVE BY DATE, ARRIVE BY TIME. If this is different please enter it here
Time you are able to return home (optional/approximate)
Do you require a flight (Commercial Air Transportation)
Do you require Medical Bus / Ground Charter (If applicable for your community )
Will you be renting a vehicle (in the appointment community)?
Will you be travelling by Private Vehicle
Do you require accomodations

Traveler Information (as displayed on your government issued photo ID)

Name
Name
First
Last
Gender
Special Requests and Considerations
plus1 Add Escort minus1 Remove

Section B&C Continued

Number of Beds in Room
Accommodations Special Requests

Summary

A summary of everything entered will be displayed here, with option to edit

Reference#:
Benefit Officer:

Employee Name/Email

Departure Community

Appointment Community

Departure Date (will be based on flight availability)
Must Arrive by Date/Time

Return Date
Can Depart by Date/Time

Patient and Escort Names, DOB, Genders

Flight Requested

Ground Shuttle Requested

Accommodation Requested

Car Rental