HEALTH SERVICES CLAIM
Member information* (refer to your ID card)
Group/policy Section Last name First name Phone number (during business hours)
Member's mailing address City Province Postal code
Has the mailing address changed since the
last claim was made under this coverage?
No Yes
If yes, the member (in whose name the
coverage is registered) must validate that the
address has changed.
Member conrmation (please sign)
Complete for member and all persons being claimed for on this form*
Relationship to member ID number First name Last name (if dierent from above) Date of birth (YYYY-MM-DD)
Self
Spouse
Dependant
Dependant
Dependant
Other coverage*
Are you or your dependants entitled to receive comparable benets from any other insurance company, health benets company or Alberta Blue Cross plan?
No Yes
If yes, complete the following
Name of insurance company or other health benets company (or, if other Alberta Blue Cross coverage, name of employer)
First and last name of cardholder with other plan Date of birth (YYYY-MM-DD)
Policy ID number or Alberta Blue Cross group, section and ID number Eective date (YYYY-MM-DD) Cancellation date (YYYY-MM-DD)
Acknowledgement and consent*
By submitting this Health Services Claim (“claim") for processing and payment by Alberta Blue Cross, you consent and agree to the following provisions:
1. The identied services have been received and fully paid for prior to the date of this claim.
2. All information contained in this claim and any supporting documents is complete and true.
3. You authorize us to collect, use, maintain and disclose personal information relevant to this claim for the purposes of determining eligibility for coverage,
assessment, paying claims, audit, investigation, underwriting, administration, and claim management.
4. You acknowledge and agree that your, or your spouse and dependants’, personal information may only be collected from and released to a third party
(health care professional, practitioner, or insurer or agent of record) only when needed for a purpose stated above.
5. You conrm you are authorized by your spouse and dependants to consent to this authorization on their behalf.
6. You understand that you can revoke this consent at any time in writing; however, if consent is withheld or revoked coverage may be denied or rescinded.
7. You understand why you have been asked to disclose this information and are aware of the risks and benets of consenting or refusing to consent.
8. If there is an overpayment, you authorize the recovery of the full amount of the overpayment from any amount payable to you under your benet plan(s).
9. You conrm for the purposes of verifying or auditing paid claims, you, your spouse and dependents will co-operate fully with Alberta Blue Cross.
10. You understand Alberta Blue Cross is relying on this signed acknowledgement and consent when verifying paid claim(s).
11. You agree that this consent shall be eective on the date noted below and shall be valid for the duration of the time coverage is in force.
Signature of member (required)
Date (YYYY-MM-DD)
Signature of patient/claimant (or parent/guardian)
Note: This consent complies with Alberta’s Health Information Act and Personal Information Protection Act and the federal Personal Information Protection and
Electronic Documents Act. For a copy of our privacy policies, or questions about our personal information policies and practices, please refer to ab.bluecross.ca or
email privacy compliance ocer at privacy@ab.bluecross.ca.
Please ensure you ll out the claim section on next page
10009 108 Street NW, Edmonton, Alberta T5J 3C5
*All sections must be completed, before your claim
can be processed. This includes other coverage.
