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)
Phone number (during business hours)
Member's mailing address
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.
Complete for member and all persons being claimed for on this form*
Relationship to member
Last name (if different from above)
Date of birth
Are you or your dependents entitled to receive comparable benefits from any other insurance company, health benefits company or Alberta Blue Cross plan?
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
Policy ID number or Alberta Blue Cross group, section and ID number
Please ensure you fill out the claim and signature section on next page
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
amount charged and paid.
Coordination of Benefits (COB) is a standard practice among benefit carriers in Canada. COB
Toll free from areas outside these major centres
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