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Use this form if you were injured in an accident to provide the details and circumstances of the accident as part of your Short or Long Term Disability application.
ONLY for Blue Choice® and Personal Choice plans. Use this form to add a dependent to your Blue Choice® or Personal Choice Plan who is more than 30 days old.
Use this form to add a spouse or dependent to your Blue Assured®, Seniors Plus Plan or Health Plus plan. This form is also used to add a newborn under 30 days of age to a Blue Choice® or Personal Choice Plan.
Application for benefits – employee statement
Use this form to detail your job description and responsibilities when applying for Short or Long Term Disability benefits.
Application for benefits – employer statement
When applying for Short or Long Term Disability benefits, this form must be completed by your employer and outlines job duties and responsibilities.
Attending physician statement Long Term Disability claim
This form must be filled out by your physician and provides additional information regarding your Long Term Disability benefits application.
Attending physician statement Short Term Disability claim
This form must be filled out by your physician and provides additional information regarding your Short Term Disability application.
Attending physician statement for Critical Illness
This form must be filled out by your physician and provides additional information regarding your Critical Illness claim application.
Accidental Dismemberment claim form - group plan
Use this form to submit an Accidental Dismemberment claim. This form contains sections that must also be filled out by your physician to provide additional information regarding your Accidental Dismemberment application as well as by your employer.
Accidental Dismemberment claim form - personal plan
Use this form to submit an Accidental Dismemberment claim. This form contains sections that must also be filled out by your physician to provide additional information regarding your Accidental Dismemberment application.
The baggage claim form can be used to submit expenses for lost, stolen, damaged or delayed baggage.
Use this form to assign or update your beneficiaries. A beneficiary receives payment from your Life Insurance and/or Accidental Death and Dismemberment plan if you pass away.
Critical Illness claim form - group plan
Use this form to apply for a Critical Illness benefits. Please note you will also need to provide a completed Attending physician statement for Critical Illness form also found on this page.
If you are submitting a Short Term Disability claim for an absence related to the coronavirus and do not have an attending physician statement, we require you use this form to confirm your symptoms and any medical treatment you may have received for your condition.
Consent to disclose personal health information
Use this consent form if you are 18 years of age or older and want Alberta Blue Cross® to provide personal health information to another individual. You may, for example, want Alberta Blue Cross® to provide your personal health information to another adult (such as your spouse, child, a relative, a friend or a lawyer). If the person who is the subject of the information request is incapable of making personal decisions or of understanding or signing the form, please contact our Customer Services department for a different consent form.
Dental claims/treatment plan form
This form is used to submit all dental claims including accidental dental services.
Your employer must fill out this form when you are moving from Short to Long Term Disability benefits. This form helps us work with other carriers to create a pending Long Term Disability file.
When on Long Term Disability benefits, six months prior to the two-year term, complete this form to provide information on your education and work history. This will help us put together a plan for retraining or returning to work.
Submit this form to report any changes to an existing employee's status. These changes must adhere to the Group Contract.
Submit this form to add eligible employees (such as those who have fulfilled the requirements of the Group Contract.)
Foot orthotic and orthopedic shoe claims
This form is a fabrication form that must be filled out by your healthcare provider for custom orthotics.
GNWT foot orthotic and orthopedic claims checklist
This form is a fabrication form that must be filled out by your healthcare provider for custom orthotics. (Government of the Northwest Territories)
Submit this form to report any changes to an existing employee's status. These changes must adhere to the Group Contract.
This form is used to submit claims for products or services such as prescription drugs, private or semi-private hospital accommodation, ambulance, psychology services, physiotherapy, chiropractic, wheelchairs, vision care and hearing aids.
Health spending account claim form
If you have a health spending account, you may use this form to submit eligible medically-related claims for reimbursement through it. The types of claims that you may submit through your account are described in detail on the claim form.
Health/dental plan rate reimbursement form
This form is used to request reimbursement of your health or dental plan rates. It must be submitted along with a health spending account claims form, and must be signed by your employer.
Complete this form to make your beneficiary irrevocable. An irrevocable beneficiary receives payment from your Life Insurance and/or Accidental Death and Dismemberment plan if you pass away. They cannot be removed as your beneficiary without their written consent.
Your employer must fill out this form detailing your position and duties as part of your application for Short or Long Term Disability benefits.
Life Insurance claim form - group plan
Use this form to submit a Life Insurance or Accidental Death claim. Please note that this form contains sections that will need to be filled out by your employer.
Life Insurance claim form - personal plan
Use this form to submit a Life Insurance or Accidental Death claim.
Optical Assistance for Seniors program receipt submission slip
This slip may be used to submit eligible claims for reimbursement through this program.
Over-age dependent declaration
Submit this form to declare
- an unmarried child over the dependent age but under the maximum age specified in the Group Contract who is attending an accredited educational institution on a full-time basis; or
- an unmarried child, over the dependent age as specified in the Group Contract, but fully dependent due to mental or physical infirmity.
Preauthorized Debit (PAD) agreement
The Preauthorized Debit (PAD) agreement form gives us permission to take monthly payments from your account. After completing the form, please attach a cheque marked "Void" to it, sign it and fax or mail it to us at the address on the form. If you have already arranged for your payments to be withdrawn automatically from your account, but need to change your bank or bank account information, you may use this form.
Preauthorized Debit for the Non-Group program
Submit this form to arrange to have payments for Non-Group Coverage (group 1) automatically withdrawn from your bank account.
Preauthorized monthly debit and direct deposit of claims information
Submit this form if you want to change previous banking information or give permission for Alberta Blue Cross® to withdraw monthly payments FROM your account and TO directly deposit claims to the same or different bank account. Or, save time and stamps by registering for direct deposit online through the member site.
Use this form to remove a dependent from your personal health and dental plans.
Submit this online form to request replacement ID cards or a copy of your plan contract. We'll send the documents you requested within 10 business days via Canada Post. Save time by registering for direct deposit online through the member site.
Request or change of direct deposit for claims payments
Submit this form to arrange to have your claim payments deposited directly into your bank account or to change the banking information we have on file for you.
Travel insurance medical emergency claim forms
Choose the form that applies to you to submit expenses.
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Travel insurance claim form (coverage through an existing plan)
Use this form if you have Alberta Blue Cross® coverage for travel insurance through a personal or group plan.
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Travel insurance claim form (coverage through a purchased plan)
Use this form if you purchased a travel insurance plan, including Top-Up insurance.
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Visitors to Canada claim form
Use this form if you purchased Visitors to Canada coverage.
Travel refund request
To request a travel refund, call us:
Monday to Friday
8:30 a.m. to 5 p.m. (MT)
1-800-394-1965 and select option 4
Trip cancellation and trip interruption form
The trip cancellation or interruption claim form can be used to submit expenses for a cancelled or interrupted trip.
Wellness spending account claims – Generic PDF form
Use this form if you already know the expense categories used by your benefit plan.
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Your claim may be eligible for online submission. Save time and paper with contactless claiming on our member site today.