Alberta COVID-19 Pharmacy Immunization Program

Find out more information about participating pharmacies.

Plan administrators Providers Forms Careers Blog Newsroom

Government-sponsored

Forms

Government-sponsored

Did you know?

You have 24/7 access to your benefits through our member site and app—anywhere, anytime.

Register today Sign in now

Forms for government-sponsored program participants

Listed below are the forms most frequently used by government-sponsored program participants including Coverage for Seniors (Group 66), Non-group Coverage (Group 1) and the Optical Assistance for Seniors Program (Group 101) sponsored by Alberta Health, and the following Government of the Northwest Territories programs: Seniors Programs (Group 60), Specified Disease Condition Program (Group 21992) and Métis Health Benefits Program (Group 19866).

Please contact Customer Services with your questions about the eligibility of products or service.

To be eligible for reimbursement, claims must be received by Alberta Blue Cross® within 12 months of the service date. The service must have been provided after the effective date of your coverage.

Receipt Submission Slip (ABC 82551)

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

Health Services Claim (ABC 20039)

This form is used to submit claims for eligible products or services.

Dental Claim/Treatment Plan (ABC 20041)

This form is used to submit all eligible dental claims and for changing or updating your file information.

Consent to Disclose Personal Health Information (ABC 30662)

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.

Request or Change of Direct Deposit for Claims Payments (ABC 30882)

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.

Registration for Preauthorized Monthly Payments (ABC 31289)

Submit this form to arrange to have payments for Non-Group Coverage (group 1) automatically withdrawn from your bank account.

Questions?

If you have any questions about your own claim please call Alberta Blue Cross®. The identification number of the individual who receives the service should be quoted on all claims and correspondence sent to Alberta Blue Cross®. This number is displayed on the back of your Alberta Blue Cross® card.

Contact information Phone number
Edmonton 780-498-8000
Calgary 403-234-9666
Toll free 1-800-661-6995