Fillable Health Services Claim Form - Alberta Blue Cross printable pdf download

HEALTH SERVICES CLAIM

*All sections must be completed before your claim

10009 108 Street NW, Edmonton, Alberta T5J 3C5

can be processed. This includes other coverage.

Member information* (refer to your ID card)

Group

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

If yes, the member (in whose name the

Member confirmation (please sign)

claim was made under this coverage?

coverage is registered) must validate that the

address has changed.

__________________________________________________

Yes

Complete for member and all persons being claimed for on this form*

Relationship to member

ID number

First name

Last name (if different from above)

Date of birth

Self

YYYY

Spouse

YYYY

Dependant

YYYY

Dependant

YYYY

Dependant

YYYY

Other coverage*

Are you or your dependents entitled to receive comparable benefits from any other insurance company, health benefits company or Alberta Blue Cross plan?



Yes

If yes, complete the following

Name of member, name of insurance company or other health benefits company or, if other Alberta Blue Cross coverage, name of employer

Date of birth

YYYY

Policy ID number or Alberta Blue Cross group, section and ID number

Effective date

Cancellation date

YYYY

Please ensure you fill out the claim and signature section on next page 

Receipts (

Explanation of benefits and claims payment

NOTE: Receipts and invoices with incomplete information will be rejected)

1. Attach original paid receipts for each expense claimed and keep copies for your records as

1. An Explanation of Benefits statement, indicating how this claim was assessed, will be sent

these receipts will not be returned. If you have claimed these expenses under another plan,

to the member to be used for income tax purposes or to claim under other coverage. If you

the original Explanation of Benefits (see explanation) from that plan and copies of receipts

are being reimbursed, a cheque will accompany the statement. If your claim is complete

must be attached to this claim. All original receipts must indicate the following information:

with all the necessary receipts and documents, the Explanation of Benefits and cheque (if

first and last name of individual receiving the service, date or dates on which the service was

appropriate) will be mailed approximately two weeks after we receive your claim.

obtained, the service or product purchased, the service provider's name and address and the

Edmonton

780-498-8000

Calgary

403-234-9666

amount charged and paid.

Grande Prairie

780-532-3505

Lethbridge

403-328-1785

Other coverage

Medicine Hat

403-529-5553

Coordination of Benefits (COB) is a standard practice among benefit carriers in Canada. COB

Red Deer

403-343-7009

Toll free from areas outside these major centres

1-800-661-6995

allows people with more than one plan to maximize their coverage.

Questions about privacy? Call 1-855-498-7302, contact us through our web site or write to

If you are claiming expenses for your spouse and your spouse is covered for those expenses

Privacy Matters at the address on this form. Visit our web site at

under another health benefit plan, you must submit the claim to your spouse’s plan first. If both

you and your spouse have health benefit coverage, your children must claim under the plan of

Mail your claim to

the parent with the earliest birthday (month and day) in the calendar year. For example, if your

Alberta Blue Cross Health Services

birthday is May 1 and your spouse’s is June 5, your children will claim under your plan first.

10009 108 Street NW, Edmonton, AB T5J 3C5

®*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans.

Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan. ®† Blue Shield is a registered trade-mark of the Blue Cross Blue Shield

Association. ABC 20039 2016/08

Health Services Claim Form - Alberta Blue Cross

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