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Add a dependant

ONLY for Blue Choice and Personal Choice plans. Use this form to add a dependant to your Blue Choice or Personal Choice Plan who is more than 30 days old.


Add a dependant
Use this form to add a spouse or dependant to your Blue Assured, Seniors Plus Plan or Health Plus plan. This form is also used to add a newborn under 30 days of age to a Blue Choice or Personal Choice Plan.


Baggage claim form

Use these forms to submit cancellation, interruption and baggage claims.


Beneficiary Appointment or Change

Submit this form to notify us of the beneficiary designated in your policy. (Beneficiaries receive benefits upon the death of the insured.)


Confirmation of illness

If you are submitting a Short Term disability claim for an absence related to the coronavirus and do not have an Attending Physician Statement, we require you use this form to confirm your symptoms and any medical treatment you may have received for your condition.


Consent to Disclose Personal Health Information

Use this consent form if you are 18 years of age or older and want Alberta Blue Cross to provide personal health information to another individual. You may, for example, want Alberta Blue Cross to provide your personal health information to another adult (such as your spouse, child, a relative, a friend or a lawyer). If the person who is the subject of the information request is incapable of making personal decisions or of understanding or signing the form, please contact our Customer Services department for a different consent form.


Dental Claims/Treatment Plan form

This form is used to submit all dental claims including accidental dental services.


Emergency Out of Province/Out of Country Claims

Use this form to submit emergency medical expenses incurred while travelling. These could include expenses such as the following: ambulance, hospital, airfare and vehicle return.


Employee Benefit Changes

Submit this form to report any changes to an existing employee's status. These changes must adhere to the Group Contract.


Employee Benefits Application

Submit this form to add eligible employees (i.e. those who have fulfilled the requirements of the Group Contract.)


Health and Dental Changes

Submit this form to report any changes to an existing employee's status. These changes must adhere to the Group Contract.


Health Services Claim form

This form is used to submit claims for products or services such as prescription drugs, private or semi-private hospital accommodation, ambulance, psychology services, physiotherapy, chiropractic, wheelchairs, vision care and hearing aids.


Health Spending Account Claim form

If you have a health spending account, you may use this form to submit eligible medically-related claims for reimbursement through it. The types of claims that you may submit through your account are described in detail on the claim form.


Health/Dental Plan Rate Reimbursement Form

This form is used to request reimbursement of your health or dental plan rates. It must be submitted along with a Health Spending Account Claims form, and must be signed by your employer.


International Service/Expatriate Claims

Use this form to submit expenses for health services you obtained while working outside Canada.


Irrevocable Beneficiary Waiver of Rights

Use this form to change the beneficiary designation, the irrevocable beneficiary must consent to waive their rights by completing this form. After this form is completed and received by Alberta Blue Cross®, you may change your beneficiary designation by completing a Beneficiary Designation form.


Notify us of a name change

Only for Individual plan members


Optical Assistance for Seniors program receipt submission slip

This slip may be used to submit eligible claims for reimbursement through this program.


Orthopedic shoe and foot orthotic fabrication form/medical supply checklist

Claiming for orthopedic shoes, foot orthotics or surgical stockings? View the fabrication form (p.1) and requirements checklist (p.2).


Over-Age Dependent Declaration

Submit this form to declare

  • an unmarried child over the dependent age but under the maximum age specified in the Group Contract who is attending an accredited educational institution on a full-time basis, or
  • an unmarried child, over the dependent age as specified in the Group Contract, but fully dependent due to mental or physical infirmity.

Preauthorized Debit (PAD) Agreement

The Preauthorized Debit (PAD) Agreement form gives us permission to take monthly payments from your account. After completing the form, please attach a cheque marked "Void" to it, sign it, and fax or mail it to us at the address on the form. If you have already arranged for your payments to be withdrawn automatically from your account, but need to change your bank, or bank account information, you may use this form.


Preauthorized Debit for the Non-Group program

Submit this form to arrange to have payments for Non-Group Coverage (group 1) automatically withdrawn from your bank account.


Preauthorized Monthly Debit and Direct Deposit of Claims Information

Submit this form if you want to change previous banking information or give permission for Alberta Blue Cross to withdraw monthly payments FROM your account and TO directly deposit claims to the same or different bank account. Or, save time and stamps by registering for direct deposit online through the plan member secure site.


Remove a spouse or dependant

Use this form to remove a dependant from your individual health and dental plans.


Replacement ID cards

Submit this online form to request replacement ID cards or a copy of your plan contract. We'll send the documents you requested within 10 business days via Canada Post. Save time by registering for direct deposit online through the plan member secure site.


Request or Change of Direct Deposit for Claims Payments

Submit this form to arrange to have your claim payments deposited directly into your bank account or to change the banking information we have on file for you.


Statement of Account Reconciliation

Submit this form to outline your monthly premium payment.


Submit an Address change online

Only for individual plan members


Travel insurance claim form

Use this form to submit emergency medical expenses incurred while travelling.


Travel Refund Request form

Use this form to request a refund for the previously submitted travel request.


Wellness spending account claims – Generic PDF form

Use this form if you already know the expense categories used by your benefit plan.


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Your claim may be eligible for online submission. Save time and paper with contactless claiming on our member site today.