Transcription of D D Unsigned forms (Sections C and D) will be returned.
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D D Unsigned forms (Sections C and D) will be returned.
AHC0208W Rev. 2022-01 Current Year Only - Based on 2021 Taxation YearApplication for Alberta Blue Cross Non-GroupCoverage premium Subsidy 2022-2023 Please read the eligibility and program information in the information brochure before completing this application is only required if you have Alberta Blue Cross Non-Group form can only be used for the period April 1, 2022 to March 31, 2023 and is based on 2021 tax forms (Sections C and D) will be you have a spouse or partner, they must complete and sign (Sections G and H) on last name is My first name is My middle name isMy current mailing address isCity/Town Province/Territory Country Postal codeSection A - Account Holder s Personal Information (Please print)My personal health number is Section B - Account Holder's Income Information Signature of account holderSection C - Alberta Health Certification and AuthorizationI have read the information on this form and certify that the information given by me is true and authorize Alberta Health to disclose my registration information to the Canada Revenue Agency for the purpose of verifying my eligibility for a premium subsidy under the Health Insurance Premiums Regulations.
a premium subsidy under the Health Insurance Premiums Regulations and will not be disclosed to any other person or organization without your approval. If you have any questions regarding the collection of this information, please contact an Alberta Health representative at the address or telephone numbers provided above. Mailing Address Alberta ...
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