Health professional business forms

Forms for doing business with the Alberta Health Care Insurance Plan (AHCIP), reciprocal billing, and additional resources.

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AHCIP business forms

Facility Registration form AHC0910A – application to register facilities and professionals providing services under the Alberta Health Care Insurance Plan (AHCIP)

​The updated version includes additional information about accreditation letters.

Practitioner/Allied Practitioners Information form AHC11234 – application to register practitioners/allied practitioners and professional corporations providing services under the AHCIP

Physician Skill Validation form AHC13188 – application to validate physician skills providing services under the AHCIP

Business Arrangement and Relationships Application form AHC11236 – to set up a new business arrangement, change or end information on an existing business arrangement, or to change information about your relationship with an existing business arrangement

Out of Province Physician Registration Attestation form AHC13398 – attestation to register practitioners/allied practitioners and professional corporations providing services under the AHCIP

Business Address Change form AHC11459 – application to update your business address

Direct Deposit Request AHC1143 – application to redirect the deposit of claims on an existing business arrangement

Request for Statement of Assessment / Account AHC0002 – application for online request of statements of Accounts and Assessments

Patient Information Update form AHC2148 – for patients who have a change or correction to their name, date of birth, or address

Request for Breast Surgery form ACH12140 – application to request breast surgery on behalf of Albertan by any licensed physician or nurse practitioner with extensive training or clinical experience in assessing and managing the mental health needs of the transgender population in Alberta

99.09 Claim Summary – application to request compensation for unlisted procedure performed by licensed practitioner

Reciprocal billing

Hospital Reciprocal Claims Guide

Valid Canada Health Care Cards – 11x17 poster showing samples of valid health care cards from each province and territory

Hospital Reciprocal Outpatient Services Claim form AHC0216B

Hospital Reciprocal In-Patient Services Claim form AHC0471

Declaration of Hospital Insurance Coverage form AHC0472

Summary Statement Hospital In-Patient Charges form AHC0483

Summary Statement Hospital Outpatient Charges form AHC0562

Quebec Claim for Physician / Practitioner Services form – used by Alberta physicians and other practitioners providing services to residents from Quebec

  • Complete form and send to:
    Régie de l'assurance maladie
    Case postale 500
    Québec (Québec)  G1K 7B4