Use this form to have payment sent directly to the provider of a service. Completed forms are given to the supplier (i.e. chiropractor) who submits it with the claim.
Fill out this form out when you have a change in: address, coverage, name, dependents or spouse. Submit this form to your Plan Administrator at your place of employment.
Use this form to claim for medical expenses and services, vision and extended health. Mail this form directly to Alberta Benefits with original receipts.
Fill out this form to authorize payment for claims directly to your bank account via electronic fund transfer.
Use this form to apply to extend a Dependant’s coverage. Submit completed and original forms to your Plan Administrator; retain a copy for your files. For disabled Dependants, please see the form below.
Use this form to apply to extend a disabled Dependant’s coverage. Send completed and original forms to your Plan Administrator; retain a copy for your files.
Use this form to register a change in your beneficiary. Send completed and original forms to your Plan Administrator; retain a copy for your files.