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 conrmation (please sign)
Complete for member and all persons being claimed for on this form*
Relationship to member ID number First name Last name (if dierent from above) Date of birth (YYYY-MM-DD)
Self
Spouse
Dependant
Dependant
Dependant
Other coverage*
Are you or your dependants entitled to receive comparable benets from any other insurance company, health benets company or Alberta Blue Cross plan?
No Yes
If yes, complete the following
Name of insurance company or other health benets 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 Eective 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 identied 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 conrm 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can revoke this consent at any time in writing; however, if consent is withheld or revoked coverage may be denied or rescinded.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 benets 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 benet plan(s).
9. You conrm 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 eective 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 ocer 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.
Claim information* (please follow instructions, see reverse)
Date of service
(YYYY-MM-DD)
Service description or prescription number D.I.N.
(prescriptions only)
Amount claimed
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
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
Receipts (
NOTE: Receipts/invoices with incomplete information will be rejected)
Attach original paid receipts for each expense claimed and keep copies for
your records, as these receipts will not be returned. If you have claimed these
expenses under another plan, the original Explanation of Benets (see explanation)
from that plan and copies of receipts must be attached to this claim. All original
receipts must indicate the following information: rst and last name of individual
receiving the service, date or dates on which the service was obtained, the service
or product purchased, the provider of service’s name and address and the amount
charged and paid.
Other coverage
Coordination of Benets (COB) is a standard practice among benet carriers in
Canada. COB allows people with more than one plan to maximize their coverage.
If you are claiming expenses for your spouse and your spouse is covered for those
expenses under another health benet plan, you must submit the claim to your
spouse’s plan rst. If both you and your spouse have health benet coverage, your
children must claim under the plan of the parent with the earliest birthday (month
and day) in the calendar year. For example, if your birthday is May 1 and your
spouse’s is June 5, your children will claim under your plan rst.
Explanation of Benets and claims payment
An Explanation of Benets statement, indicating how this claim was assessed,
will be sent to the member to be used for income tax purposes or to claim
under other coverage. If you are being reimbursed, a cheque will accompany
the statement. If your claim is complete with all the necessary receipts and
documents, the Explanation of Benets and cheque (if appropriate) will be mailed
approximately two weeks after we receive your claim.
You can view your claim statement online by signing in to our member site at
ab.bluecross.ca.
EDMONTON 780-498-8000
CALGARY 403-234-9666
GRANDE PRAIRIE 780-532-3505
LETHBRIDGE 403-328-1785
MEDICINE HAT 403-529-5553
RED DEER 403-343-7009
Toll free from areas outside these major centres 1-800-661-6995
Questions about privacy? Call 1-855-498-7302, contact us through our website
or write to Privacy Matters at the address on this form. Visit our website at
ab.bluecross.ca.
MAIL YOUR CLAIM TO
Alberta Blue Cross Health Services
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 Benets
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 55063\20039 2020/01
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