Government programs forms

Constituents are required to fill out several forms to apply for government-sponsored programs and to make claims when they receive a medical treatment. The following is a list of forms categorized by program.

Program-specific forms

Most commonly used forms
Coverage for Seniors
Optical Assistance for Seniors
Non-group coverage
Palliative coverage
Alberta Child Health Benefit
Alberta Adult Health Benefit

Most commonly used forms

Health Services Claim

Request or Change of Direct Deposit for Claims Payments

Dental Claim/Treatment Plan

Overage Dependent Declaration (Individual plan)

Registration for Preauthorized Monthly Payments — Non-Group Coverage

Overage Dependent Declaration (Employer-sponsored plan)

Coverage for Seniors

Coverage for Seniors Proof-of-Age Declaration form

To be eligible for Coverage for Seniors, individuals must provide proof of being 65 years of age or older.

Optical Assistance for Seniors

Optical Assistance for Seniors application form

Eligibility is determined by a senior’s total income as reported to the Canada Revenue Agency (CRA) in the previous tax year.

Receipt Submission slip

If the optical provider does not use online claim submission, please use this convenient slip to submit the original receipt to Alberta Blue Cross^® for reimbursement.

Non-Group Coverage

Non-Group Coverage application form

Non-Group Coverage is available to all Alberta residents under 65 years of age and their dependents, as registered under the AHCIP.

Application for premium subsidy (current year)

Download the application for premium subsidy for the current benefit year.

Application for premium subsidy (retroactive)

Download the application for premium subsidy for the current and previous benefit years.

Registration for Preauthorized Monthly Payments — Non-Group Coverage

Authorization form for Alberta Health to automatically withdraw funds from members bank account for payment of premiums.

Palliative Coverage

Palliative Coverage Program application form

The application form must be completed and signed by both the patient or guardian and physician or nurse practitioner.

Alberta Child Health Benefit

Alberta Child Health Benefit application form

Low-income families can apply to this program to get eyeglasses, prescription drugs and dental care for their children.

Alberta Adult Health Benefit

Alberta Adult Health Benefit application form

The Alberta Adult Health Benefit program covers health benefits for Albertans in low-income households who are pregnant or have high ongoing prescription drug needs.

Land acknowledgement

We begin by acknowledging that we are on traditional lands, referred to as Treaty 6, Treaty 7 and Treaty 8 territory, and all the people here are beneficiaries of these peace and friendship treaties.

This territory is the home for many Indigenous Peoples, including the Blackfoot, Cree, Dene, Saulteaux, Ojibwe, Stoney Nakota Sioux, and Tsuut’ina peoples, and the Métis Nation of Alberta and the Métis Settlements.

We respect the Treaties that were made on these territories, we acknowledge the harms and mistakes of the past, and we dedicate ourselves to moving forward in partnership with Indigenous communities in a spirit of reconciliation and collaboration.