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Authorization & consent

I understand that the personal information and personal health information provided herein as well as any other personal information and personal health information currently held or collected in the future by Manitoba Blue Cross and/or Blue Cross Life Insurance Company of Canada (collectively referred to as “Blue Cross”) may be collected, used, or disclosed to administer the terms of the policy of which I am an eligible member, to develop and recommend suitable products and services to me, and to manage the Company’s business.

Depending on the type of coverage I carry, limited personal information or personal health information may be collected from and/or released to a third party. These include other Blue Cross organizations, licensed physicians and/or any other healthcare professionals or institutions, health and life insurers, government and regulatory authorities, and other third parties when required to administer the benefits outlined in the policy of which I am an eligible member.

I understand that my personal information and personal health information will be kept confidential and secure. I understand that I may revoke my consent at any time; however, if consent is withheld or revoked, the coverage may be denied or rescinded. I understand why my personal information and personal health information is needed and am aware of the risks and benefits of consenting or refusing to consent to its disclosure. For additional information regarding Blue Cross’ privacy policies as to the collection, use, or disclosure of my information, I may contact Manitoba Blue Cross at 204.775.0151 or at www.mb.bluecross.ca.

As the disabled dependent checkbox has been selected, please complete the Manitoba Blue Cross Disabled Dependent form and return to Manitoba Blue Cross to confirm eligibility. Please contact our office if further clarification is required.

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View personal plan options

Before you go...

Consider a personal plan from Manitoba Blue Cross. Personal plans are available for purchase outside of your group benefits package.

Wellness plan

Only $60 a year! Unlock exclusive wellness programs and services on our digital wellness platform.

From fitness solutions with hundreds of workout programs to caregiver support, financial planning and mental health resources, take charge of your well-being with a wide range of online health and wellness tools at your fingertips.

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Blue Cross Life® Insurance

Get up to $10 million in coverage! Take care of your family's financial needs when it matters most with term life insurance from Canada's Most Respected Life Insurance Company. Critical illness coverage can also be added.

Already have life coverage? Add another layer of financial security to ensure your family is well protected.

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*Underwritten by Assumption Life

®*The Blue Cross symbol and name, Colour of Caring and mybluecross are registered marks of the Canadian Association of Blue Cross Plans, independently licensed by Manitoba Blue Cross. *†Blue Shield is a registered trade-mark of the Blue Cross Blue Shield Association.

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