Request website access and add a practitioner forms

Registration choice *

Individual provider (authorizations only)

(each provider has their own login ID and password)

Individual provider (claims only)

(each provider has their own login ID and password)

Clinic provider (authorizations only)

(a single sign on for providers in the same office sharing the same login ID and password)

Clinic provider (claims only)

(a single sign on for providers in the same office sharing the same login ID and password)

Provider type *

Occupational therapists

Service centres

Specialty supplier

Speech language pathologists

Indicate your unique login ID below.

Login ID *

Your login ID must contain three to fifteen letters and/or numbers and no spaces or symbols.

Please enter your login ID

Legal name of the individual provider or clinic *

Please enter your legal name of the individual provider or clinic.

Operating/practice name (if different from legal name)

Please enter your operating/practice name.

Phone *

Please enter a valid phone number.

Fax

Please enter a valid fax number.

Business address *

Please enter your business address.

City or town *

Please enter your city/town.

Province *

Please select your province.

Postal code *

Please enter your postal code.

Mailing address is same as above

Issue payment to *

Please enter your name

Payment address *

Business address

Mailing address

Other address

(indicate below)

First name *

Please enter contact first name

Last name *

Please enter contact last name

Initial

Please enter contact initial

Phone *

Please enter a valid contact phone number.

Email *

Please enter a valid contact email address.

Fax

Please enter a valid contact fax number.

Authorized representative *

Please enter authorized representative's name

I, as an authorized representative of the above-mentioned health services provider, hereby authorize Alberta Blue Cross^® to enable this practice or place of business to participate in online claim submission and processing for health services rendered, according to the terms of the Alberta Blue Cross^® Health Services Provider Web Site Policy and Online Billing Agreement.

I agree and consent to receive information about suitable products, programs and services from Alberta Blue Cross^® that may be of interest to me through electronic communication methods. You may unsubscribe at any time.

I authorize Alberta Blue Cross^® to list my practice's name, address and telephone number in its online Direct-bill provider directory.

Request website access and add a practitioner forms

Request for secure website access

Login ID

Provider information

Business address

Mailing address

Payment information

Contact information

Provider validation

Authorization

Request to add a practitioner to an existing account for online direct billing

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Thank you for getting in touch with us.

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Request website access and add a practitioner forms

Request for secure website access

Login ID

Provider information

Business address

Mailing address

Payment information

Contact information

Provider validation

Authorization

Request to add a practitioner to an existing account for online direct billing

Thank you for getting in touch with us.

Thank you for getting in touch with us.