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Group plan members | Forms

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Forms for group plan members

Did you know that you can use your keyboard to type into the fields on all our PDF forms?

Dental Claims/Treatment Plans (ABC 20041)
This form is used to submit all dental claims including accidental dental services.

Health Services Claims (ABC 20039)
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 Claims (ABC 30676)
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. (Note: To apply for reimbursement of your health or dental plan rates, please use two forms: the Health Spending Account Claim form and also include the Reimbursement Form listed below.)

Taxable/Wellness Spending Account claimsNote: Each benefit plan has its own customized list of eligible expenses for taxable spending accounts. There are two ways to submit your claims:

Health/Dental Plan Rate Reimbursement Form (ABC 30980)
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 (ABC 30735)
Use this form to submit expenses for health services you obtained while working outside Canada.

Emergency Out of Province/Out of Country Claims (ABC 30741)
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.

Updating or changing 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.

Direct Deposit for Claims Payments
Making changes to your bank account information, or arranging for Alberta Blue Cross to deposit claim payments into your account is simple. Register for direct deposit online through the plan member secure site.

Over-age Dependent Declaration (ABC 30230)
(Note: Before using this form check with your group administrator. Your group may have its own customized version.)

Submit this form to declare

  1. an unmarried child over the dependent age but under the maximum age specified in the Employee Benefits booklet who is attending an accredited educational institution on a full-time basis,
  2. or an unmarried child, over the dependent age as specified in the Employee Benefits Booklet, but fully dependent due to mental or physical infirmity.

Case management forms

Application for Benefits - Employee Statement (ABC 31317)

Attending Physician's Statement - General (ABC 31043)

Job Description - (ABC 30135)

Accident Questionnaire - (ABC 30339)

Submitting your claims
Once you have opened the form, enter all requested information using your mouse and keyboard. Print and sign the form. Be sure to attach any additional supporting documentation or original receipts where required. Mail it to Alberta Blue Cross at the address indicated on the form.

 


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