Forms – Health Care Insurance Plan
Important: Due to the sensitive nature of the information required, DO NOT return forms via e-mail. Print and return your application by mail, fax or in person.
Forms – Individuals
Alberta Health Care Insurance Plan forms for individual use are listed below. You can also contact us to request a form or obtain additional information.
- For group forms, instructions and additional information, select from the links on the left.
Forms for individual use
Important: Due to the sensitive nature of the information required, DO NOT return forms via e-mail. Electronic submission is not available. Print and return your application by mail, fax or in person.
| Applying for coverage or change of status | ||
| AHC0102 | Application for Alberta Health Care Insurance Plan Coverage  |
Print only |
| AHC0107 | Notice of Change To change a name, address or add/delete family members |
Print only |
| AHC0312W | Proof of Age Declaration |
Fill & Print |
|
Premium Assistance | ||
|
AHC0208G |
Application for Premium Subsidy Current form for April 1, 2009 to March 31, 2010 based on your 2008 taxable income. |
Print only |
| Based on 2006, 2007 or 2008 taxable income
| ||
| AHC0391 | Current and Retroactive Premium Subsidy - April 1, 2007 to March 31, 2008 based on 2006 taxable income - April 1, 2008 to March 31, 2009 based on 2007 taxable income - April 1, 2009 to March 31, 2010 based on 2008 taxable income |
Print only |
| Payment Plan | ||
| AHC0104A | Pre-authorized Payment Plan |
Print only |
|
Optional health plans - Alberta Blue Cross | ||
| AHC0201 | Alberta Blue Cross Non-group Coverage |
Print only |
| ABC20039 | Alberta Blue Cross Health Services Claim form |
Print only |
| AHC0222 | Alberta Blue Cross Palliative Care Drug Program |
Print only |
| Brochures | ||
| AHC0009 | About Alberta Health Care Insurance Plan brochure |
|
| ABC40005 | Alberta Blue Cross Coverage for Seniors brochure |
|
| Non-Group | Alberta Blue Cross Non-Group Coverage brochure |
|
| ABC40501 | Alberta Blue Cross MS Drug Coverage brochure |
|
| Palliative Care | Alberta Blue Cross Palliative Care Drug Program brochure |
|
| AHC1443 | Premium Assistance Program brochure |
|
| AHC0012 | Travel Health Insurance Matters brochure |
|
New and revised forms and brochures are posted on the form pages on a regular basis. To avoid using an outdated form, we recommend you do not save any form. If you need a form, check this page to ensure you have the most current version of the form.
