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Plan Member Forms


Assignment of Benefits Form

Use this form to have payment 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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Plan Member Change Form

Fill out this form out when you have a change in: address, coverage, name, dependents or spouse. Submit this form to your Plan Administrator at your place of employment.

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Claim Form

Use this form to claim for medical expenses and services, vision and extended health. Mail this form directly to Alberta Benefits with original receipts.

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Electronic Payment Authorization Form

Fill out this form to authorize payment for claims directly to your bank account via electronic fund transfer.

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Over-Age Dependent Form

Use this form to apply to extend a Dependant’s coverage. Submit completed and original forms to your Plan Administrator; retain a copy for your files. For disabled Dependants, please see the form below.

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Disabled Dependant Form

Use this form to apply to extend a disabled Dependant’s coverage. Send completed and original forms to your Plan Administrator; retain a copy for your files.

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Change of Beneficiary Form

Use this form to register a change in your beneficiary. Send completed and original forms to your Plan Administrator; retain a copy for your files.

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