Plan Members use this form to have payment for claims sent directly to the provider of a service. Completed forms are given to the supplier (i.e. chiropractor) who submits it with the claim.
Plan Members use this form to claim for medical expenses and services, vision and extended health. Members should mail this form directly to Alberta Benefits with original receipts.
Use this form to register a change in a Plan Member’s: address, coverage, name, dependants or spouse. Plan Administrator should retain the original form for their files and register changes through the online portal.
Use this form to enroll a Plan Member in your benefit program. Send completed and original forms to Alberta Benefits; retain a copy for your files. Note: Plan Members must also be enrolled online.
Direct Plan Members to this form to extend their Depedant’s coverage. Scan and send via email or fax the completed forms to Alberta Benefits; retain originals for your files. See below for disabled Dependants.
Direct Plan Members to this form to extend a disabled Depedant’s coverage. Scan and send via email or fax the completed forms to Alberta Benefits; retain originals for your files.
Direct Plan Members to this form if they wish to change or add a beneficiary. Send their completed and original forms to Alberta Benefits; retain a copy for your files.
Use this form to remove a Plan Member from a Benefit Plan. Retain a copy for your files.