Forms for AHCIP and Blue Cross

Apply for AHCIP

• Application form for AHCIP Coverage
• Application form for AHCIP Coverage: Canadian Children of Non-Eligible Parents (PDF, 169 KB) – Use only for your Canadian child if you are the child’s parent, you have established residency in Alberta, and you, the parent, are not eligible for AHCIP coverage.

Update information

• Update or replace – AHCIP Notice of Change – UPDATE – Name, address, date of birth, gender,  replace a card
  • Find out how to get a replacement card if you lost your card or it is damaged.
• Add family – AHCIP Notice of Change – ADDITION (PDF, 303 KB)
• Remove family – AHCIP Notice of Change – DELETION (PDF, 286 KB)

Submit form

Download, complete and print the appropriate form. Do not send any information or forms by email.

Submit your application. You can:

• bring it to a participating registry
• send it by mail
• fax it to 780-422-0102

Group forms

• Employee Group Commencement and Termination form (PDF, 95 KB)

Blue Cross benefit forms

Alberta Blue Cross administers supplementary benefit plans on behalf of the Government of Alberta.

• Proof of Age for Alberta Senior Benefit Program (PDF, 149 KB)
  • Learn more about the Senior Benefit Program
• Application for Alberta Blue Cross Non-group Coverage (PDF, 174 KB)
  • Learn more about non-group coverage
• Application for Premium Subsidy for Non-Group Premiums (PDF, 157 KB)
• Current and Retroactive Premium Subsidy (PDF, 145 KB)
  • Learn more about premium subsidies for non-group coverage
• Registration for Preauthorized Monthly Payment for Non-Group Premiums (PDF, 57 KB)
• Alberta Blue Cross Health Services Claim form (PDF, 158 KB)
• Palliative Coverage Program form (PDF, 156 KB)
  • Learn more about palliative coverage

If you have questions about benefit forms, contact Alberta Blue Cross.

Find out how to claim for benefits through Alberta Blue Cross.

Statement of Benefits Paid

A Statement of Benefits Paid (SOBP) is a list of physician services paid for by the AHCIP on your behalf during a specific period. It includes the date and general type of service, physician name and the amount that was paid to the physician.

The requested SOBP is sent directly to the individual or their authorized representative.

Hospital services do not appear on the SOBP. These may be requested directly from the hospital.

How to order an SOBP

Current year

There is no cost for an SOBP for the most recent benefit year (July 1 to June 30) to the current year to date.

To request a current SOBP, download and complete the Request for Statement of Benefits Paid form (PDF, 156 KB) and mail the completed form to the AHCIP office.

Or, place an order using the automated phone system:

• Phone: 780-427-0845
• Toll free: 310-0000 before the phone number (in Alberta)

Previous years

An SOBP can be requested back to October 1, 1993. There is a fee of $25 plus GST ($26.25) per request for individuals ordering a personal SOBP directly.

Families ordering for more than one person on the same AHCIP account pay only $26.25 for everyone.

To request an SOBP from previous years:

1. Download and compete the Request for Statement of Benefits Paid form (PDF, 156 KB).
2. Mail the completed form with your payment. Only cheques or money orders are accepted, payable to 'Government of Alberta.'

Third-party requests

If a third-party such as law firm or insurance company wishes to request an SOBP on behalf of an Albertan, contact Alberta Health by emailing [email protected].

Effective January 1, 2020, the fee for third-party SOBP requests is $75 ($78.75 with GST).

SOBP help

Contact us if you need help, or are from a law firm or insurance company requiring this statement.

Office hours: 8:15 am to 4:30 pm, Monday to Friday, excluding holidays
Email: [email protected]

Contact

Due to high call volumes, it is recommended you read through our web content before you call us.

To register or update your information, go to a participating registry.

Connect with AHCIP