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AHCIP business forms
Facility Registration form AHC0910A (PDF, 1.9 MB) – application to register facilities and professionals providing services under the Alberta Health Care Insurance Plan (AHCIP)
- Instructions for Facility Registration form (PDF, 86 KB)
Practitioner/Allied Practitioners Information form AHC11234 (PDF, 209 KB) – application to register practitioners/allied practitioners and professional corporations providing services under the AHCIP
Business Arrangement and Relationships Application form AHC11236 (PDF, 226 KB) – application to register or make changes to a business arrangement providing services under the AHCIP, or to attach an accredited submitter to a business arrangement, as well as any additional providers
Business Address Change form AHC11459 (PDF, 113 KB) – application to update your business address
Direct Deposit Request AHC1143 (PDF, 118 KB) – application to redirect the deposit of claims on an existing business arrangement
Request for Statement of Assessment / Account AHC0002 (PDF, 135 KB) – application for online request of statements of Accounts and Assessments
Patient Information Update form AHC2148 (PDF, 1.0 MB) – for patients who have a change or correction to their name, date of birth, or address
Valid Canada Health Care Cards (PDF, 2.7 MB) – 11X17 poster showing samples of valid health care cards from each province and territory
Declaration of Hospital Insurance Coverage form AHC0472 (PDF, 242 KB)
Quebec Claim for Physician / Practitioner Services form (PDF, 106 KB) – 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
Annual Care Plan template (PDF, 284 KB)
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