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 Plan Administrator Forms


Assignment of Benefits Form

Plan Members use this form to have payment for claims sent directly to the provider of a service. Completed forms are given to the supplier (i.e. chiropractor) who submits it with the claim.

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Claim Form

Plan Members use this form to claim for medical expenses and services, vision and extended health. Members should mail this form directly to Alberta Benefits with original receipts.

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Plan Member Change Form

Use this form to register a change in a Plan Member’s: address, coverage, name, dependants or spouse. Plan Administrator should retain the original form for their files and register changes through the online portal.

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Plan Member Enrollment Form

Use this form to enroll a Plan Member in your benefit program. Send completed and original forms to Alberta Benefits; retain a copy for your files. Note: Plan Members must also be enrolled online.

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Over-Age Dependent Form

Direct Plan Members to this form to extend their Depedant’s coverage. Scan and send via email or fax the completed forms to Alberta Benefits; retain originals for your files. See below for disabled Dependants.

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Disabled Dependant Form

Direct Plan Members to this form to extend a disabled Depedant’s coverage. Scan and send via email or fax the completed forms to Alberta Benefits; retain originals for your files.

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Change of Beneficiary Form

Direct Plan Members to this form if they wish to change or add a beneficiary. Send their completed and original forms to Alberta Benefits; retain a copy for your files.

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Termination Form

Use this form to remove a Plan Member from a Benefit Plan. Retain a copy for your files.

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