Government-sponsored

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• Submit this form to arrange to have payments for Non-Group Coverage (group 1) automatically withdrawn from your bank account.

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.