Income Assessment For Reduced Fee Dental Care - Alberta Health Services
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1Income Assessment for Reduced Fee Dental Care
Complete the form
Send your completed form by mail, fax, email, or bring it to one of the following clinics:
Sheldon M. Chumir Dental Clinic
1213 4th St. SW Calgary AB T2R 0X7
Fax: 403.955.6899
Phone: 403.955.6888
Northeast Dental Clinic (Sunridge Mall)
200 2580 32 St NE Calgary AB T1Y 7M8
Fax: 403.944.9779
Phone: 403.944.9999
Email: community.dental@ahs.ca (please use email for program application ONLY)
Fill out this section to fi nd out if you are eligible for reduced fee dental services
Do you receive assistance from any of these government programs? ()
Program Name
Yes
No
Assured Income for the Severely Handicapped (AISH)
Alberta Adult Health Benefi t
Alberta Senior’s Benefi t
Alberta Student Finance Board Assistance (Student Loans)
First Nations Social Services Income Support
Did you answer Yes to any of the questions?
You do not qualify for reduced fee dental services
Yes
These programs already provide you with dental benefits
No, Continue
Please contact them if you have questions.
Do you have a Notice of Assessment?
(A notice that is sent to you when you fi le a tax return)
Can you get one?
No
Do not continue this form.
Use Form
No
Yes, Continue
20933 Temporary Eligibility Assessment to
find out if you qualify for emergency/urgent
Yes, Continue
dental services
Fill this out to fi nd and show your family income
(Use Line 236 on your Notice of Assessment)
Your yearly taxable income
$
_______________________
Your spouse/common law partner’s taxable income
$
_______________________
Total Combined Household Income
$
_______________________
What is your family size?
Number of persons
_____________________
Includes: You + Your spouse/ partner + Number of children under age 18
I s your family income below the
Low Income Cut-off
◄ low-income cutoff?
1 person
$ 24,949
4 persons $ 46,362
7 or more
$ 66,027
persons
No
2 persons
$ 31,061
5 persons $ 52,583
3 persons
$ 38,185
6 persons $ 59,304
Yes, Continue
Send/bring a copy of your Notice of Assessment for you and your spouse with this form
Fill this out for the person who is applying for reduced fee dental care
Last Name
First Name
Personal Health Number
Date of Birth
Gender
Phone Number
Alternate Phone Number
(yyyy-Mon-dd)
Address
City/Town
Postal Code
Alberta Health Services collects health information in accordance with Section 20 of the Health Information Act (HIA) for the purpose of providing health
services, determining eligibility for health services, or to carry out any other purpose authorized by the HIA. If you have questions about this collection, please
ask your health care provider or contact Manager, Public Health Dental Services 6th Floor, 1213 4th Street SW Calgary, AB T2R 0X7, Phone 403.955.6685.
19284 (Rev2017-08)
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