Fillable Printable Child Health Benefit Application Form - Alberta

Child Health Benefit Application Form - Alberta

Does this child have health

coverage other than standard

Alberta Health Care Insurance?

Last name

Birth date (yyyy/mm/dd)

My Personal Information

My Spouse/Partner's Information (If you are divorced or separated from your spouse/partner, do not complete this section.)

Spouse/Partner's last name First name

Spouse/Partner's Social Insurance NumberSpouse/Partner's birth date (yyyy/mm/dd) Work phone number

Social Insurance Number

First name Middle initial

HRE2939Web (2006/03)

Home phone number

Work phone number/ExtensionMailing address

My Child(ren) (List all children up to age 19 who are attending Kindergarten to Grade 12.)

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Province

Postal code

Alberta Child Health Benefit Application

The information you have provided on this application is collected under the authority of the Income and Employment Supports Act, and is in compliance with

the Freedom of Information and Protection of Privacy Act. The information will be used solely for the purpose of determining and verifying eligibility for

benefits under the Alberta Child Health Benefit (ACHB) program, and will be matched and shared with any agency, institution, government department

(federal or provincial), or other sources for this purpose. If you have questions about the collection of this information, contact Alberta Human Resources and

Employment, ACHB program at 427-6848 or toll-free outside of Edmonton at 1-877-469-5437.

Middle initial

City/Town/Municipality

Complete this form in BLACK ink. Please PRINT clearly.

Your application will be sent back to you if information is missing.

Your application will be processed within 15 days if:

Birth date (yyyy/mm/dd)

Child's last name

First name

Sex

Alberta Personal Health Number

Does this child have

Indian or Inuit status?

Does this child have health

coverage other than standard

Alberta Health Care Insurance?

Birth date (yyyy/mm/dd)

Child's last name

First name

Sex

Does this child have

Indian or Inuit status?

Birth date (yyyy/mm/dd)

Child's last name

First name

Sex

Does this child have

Indian or Inuit status?

Birth date (yyyy/mm/dd)

Child's last name

First name

Sex

Does this child have

Indian or Inuit status?

If you have more than four children, please attach another sheet listing the same information for them.

Alberta Personal Health Number

Does this child have health

coverage other than standard

Alberta Health Care Insurance?

Send your completed form to:

Alberta Human Resources and Employment

Alberta Child Health Benefit

P.O. Box 2222 Station Main

Edmonton, AB T5J 5H3

- You fill in the required blanks.

- You sign and date the "My Declaration" and "Consent" sections.

Does this child have health

coverage other than standard

Alberta Health Care Insurance?

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If you have more than four children, double click on the paperclip.

You will need Acrobat Reader 6.0 or higher in order to

complete this form online.

Policy Number/Identification Number

I understand that giving false or incomplete information, or not advising of changes in my situation may result in my children's health benefits being

suspended or terminated, or criminal charges. I could also be ordered to repay benefits I have received.

For Office Use Only

Date application received



I understand that Alberta Human Resources and Employment (AHRE) may contact any agency, institution, government department (provincial or

federal), or other sources to verify my information, to confirm whether my children qualify for this program.



I will report any changes in this information to the Alberta Child Health Benefit program.



I declare that I am a resident of Alberta and that the information on this application is true and complete to the best of my knowledge.

My Declaration

If your children have any other health coverage (other than standard Alberta Health Care Insurance) please provide:

Applicant's Last name Social Insurance Number

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Name of Policy Holder (if different from you)

Name of Insurer (i.e. Clarica, Alberta Blue Cross)

Type(s) of coverage

provided in policy

Ambulance

Prescription

Drugs

Optical

Dental

Name of Policy Holder (if different from you) Policy Number/Identification Number

Name of Insurer (i.e. Clarica, Alberta Blue Cross)

Type(s) of coverage

provided in policy

Ambulance

Prescription

Drugs

Optical

Dental

Consent for Canada Revenue Agency (Revenue Canada) to verify income

I consent to the release, by Canada Revenue Agency to Alberta Human Resources and Employment, of information from my

income tax returns and other taxpayer information about me whether supplied by me or a third party. The information will be

relevant to, and will be used solely for the purpose of determining, verifying and/or auditing my/our eligibility, and for the general

administration and enforcement of the Alberta Child Health Benefit under the Income and Employment Supports Act. This

consent is valid for the taxation year in which I sign this consent, the previous tax year, and for each taxation year that I ask for

this benefit.

My signature

Date (yyyy/mm/dd) Spouse/Partner's signature (if applicable)

Date (yyyy/mm/dd)



I understand that to be eligible for this program I must consent to Canada Revenue Agency providing tax information to AHRE.

If you have more than two other health insurers, please attach another sheet providing the same information for that coverage and

which children are covered under each plan.



Date (yyyy/mm/dd)Spouse/Partner's signature (if applicable)

Date (yyyy/mm/dd)My signature



HRE2939Web (2006/03)

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