Claim forms – Health Care Insurance Plan

Important: Due to the sensitive nature of the information required, DO NOT return forms via email. Electronic submission is not available. Print and return your application in person at an authorized registry agent office, or by mail, fax or in person.

Claims submission resources and forms

• Out-of-Province Claim for Physician / Practitioner Services  This claim form has two purposes. It is to be used by:
  1. Alberta physicians (for services that can not be billed through the medical reciprocal billing process) and other practitioners providing services to residents from other parts of Canada.
  2. Alberta residents wanting to submit a claim to the AHCIP for physician services they received in other parts of Canada.
• Quebec Claim for Physician / Practitioner Services  Used by Alberta physicians and other practitioners providing services to residents from Quebec. 
  • Complete and send to: Régie de l'assurance maladie, Case postale 500, Québec (Québec) G1K 7B4
• Facility Registration  Application to register facilities and professionals providing services under the AHCIP.
• Organization Information  Application to register professional corporation or clinic providing services under the AHCIP.
• Practitioner Information Form  Application to register practitioners and professional corporations providing services under the AHCIP.
• Business Arrangement (BA) Request  Application to register as a contract holder or business arrangement providing services under the AHCIP.
• Business Arrangement (BA) / Service Provider (SP) Relationship  Application to register as a service provider or business arrangement providing services under the AHCIP.
• Claim Form for Out of Country Health Services  Application to claim practitioner services and facility services outside Canada.
• Insurance Claim Consent and Authorization  Application for third-party requests for reimbursement of insured physician and hospital services paid on behalf of Alberta residents who obtained emergency medical services outside Canada. 
• Electronic Funds Transfer Request  Application for direct deposit of claims.
• H-Link Application for Submitter Role  Application to become an accredited submitter.
• Submitter/Client Relationship for Electronic Claim Submission  Application for an accredited submitter to submit claims electronically on behalf of a service provider.
• Blue Cross Health Services Claim Form  Fill and print