Request website access and add a practitioner forms

Who needs website access? *

An individual practitioner

You are the only health practitioner submitting claims under this account.

A clinic

You are submitting claims for multiple health practitioners who practice different health modalities, or you are an optical provider.

Please select who needs website access.

Provider type *

Audiologist

Hearing aid practitioner

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.

Please check the authorization checkbox.

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.