Fillable Health Services Claim Form - Alberta Blue Cross (Page 2 of 2) in pdf

Claim information (please follow instructions, see reverse)

Date of service

Service description or prescription number

D.I.N.

Amount claimed

(prescriptions only)

YYYY

Enter total claim amount $

SEND THIS CLAIM WITH YOUR ORIGINAL RECEIPTS TO

ALBERTA BLUE CROSS, HEALTH SERVICES, 10009 108 STREET NW, EDMONTON AB T5J 3C5

Acknowledgement and consent*

By submitting this health services claim for processing and payment by Alberta Blue Cross, and in consideration of Alberta Blue Cross processing/paying this

claim, I/we consent and/or agree to/with the following provisions:

• The identified services have been received and fully paid for prior to the date of this claim.

• All information contained in this claim and any supporting documents is complete and true.

• All personal information contained in this claim, as well as other personal information currently held or collected in the future by Alberta Blue Cross, will be used by

Alberta Blue Cross only to determine eligibility for benefits, to assess and pay claims, to administer the terms of my/our benefit plan and to verify or audit paid claims.

• My/our or my dependants’ personal information may be disclosed or exchanged only between Alberta Blue Cross and a licensed physician and/or health services

provider/professional/practitioner, institution or insurer for the purposes stated above My/our and my dependants’ personal information will otherwise be kept

confidential and secure.

• The member is authorized by his/her spouse and/or other adult dependants to disclose and receive information about them that is used solely for these purposes.

• For the purpose of verifying or auditing paid claims, I/we and any spouse/eligible dependant(s) will co-operate fully with Alberta Blue Cross.

• I/we understand why my/our and my dependants’ personal information is needed and am aware of the risks and benefits of consenting or refusing to consent to its

use as described above.

• I/we have read and understood this acknowledgement and consent and understand that Alberta Blue Cross is relying on this signed acknowledgement and consent

when assessing and paying this claim.

• I/we authorize Alberta Blue Cross to collect, use and disclose my/our and my dependants’ personal information as described above.

• I/we agree that this acknowledgement and consent shall be effective from the date of claim and shall remain in effect as long as the coverage is in force.

Signature of primary plan member

Date

Signature of Patient/Claimant (or Parent/Guardian)

YYYY

*This consent is obtained in accordance with Alberta’s Health Information Act, the Personal Information Protection Act and the federal Personal Information Protection and

Electronic Documents Act. I/we refers to the one or more individuals signing and/or submitting this form.