Application for Alberta Health Care Insurance Plan Coverage

1 AHC0102 (2005/05)Page 1 Who should complete this Application ?Permanent residents of Alberta are required to complete thisapplication in order to receive Alberta Health Care Insurance Plan(AHCIP) Coverage . Please complete page 3 if registering yourselfand your spouse/adult interdependent partner (if applicable). Ifyou have dependants , complete page 4 as well. Page 1 and 2provide information about the AHCIP, and should be read beforecompleting this residentsAll permanent residents of Alberta must apply for AHCIP coveragefor themselves and their dependants . A resident of Alberta is aperson who is: legally entitled to be or to remain in Canada and makes his/her permanent home in Alberta ; committed to being physically present in Alberta for at least183 days in a 12 month period; not claiming residency or obtaining benefits under a claim ofresidency in another province, territory or country; and any other person deemed by the regulations to be a tourist, transient or visitor to Alberta is not a of Alberta who already have a personal healthnumber and are being added to an active AHCIP account donot need to complete this Application .

2 Instead, complete aNotice of Change (AHC0107) form which can be obtained fromyour employer, our website, or by contacting us at the addressesor telephone numbers listed on page 3 of this : If you are a member of the Canadian Armed Forces,the Royal Canadian Mounted Police or are an inmate of afederal correctional institution, you have Health Coverage withthe federal government. However, if you have dependants thatreside in Alberta , they are required to apply for AHCIP dependants are: married spouses (must register together); separated spouses (may register together or separately); adult interdependent partners (may register together orseparately); children (includes adopted children, foster children and wards)who are under 21, single and wholly dependent; single children over 21 who are wholly dependent because ofphysical or mental disabilities.

3 And single children under 25 who are enrolled in three or morecourses at an accredited educational interdependent partnersIndividuals who are not married may register under the AHCIP asadult interdependent person is an adult interdependent partner if: the person has lived with the other person in a relationship ofinterdependence for a continuous period of not less than 3 years, or of some permanence, if there is a child of the relationshipby birth or adoption,or the person has entered into an adult interdependent partneragreement with the other adult interdependent partner will hereafter be referred to as partner .To receive Coverage new and returning Albertans need toprovide documentation that proves they are a resident ofAlberta and entitled to Coverage . For examples of thedocuments required, refer to page does Coverage start?

4 If you move to Alberta from another Canadian province orterritory, you are eligible for Coverage on the first day of the thirdmonth following the date you established permanent residencyhere, provided you apply before the first day of the fourth monthafter your arrival. Alberta Health and Wellness will determine whencoverage begins for individuals who apply you move ahead of your family, please arrange to continuecoverage for yourself and your dependants in the province/territoryfrom which you came. You will be eligible for AHCIP Coverage onthe first day of the third month following the date your family joinsyou in you move to Alberta from outside Canada you are eligible forcoverage on the date you arrive as long as you apply within threemonths of arriving in Alberta . Eligibility will be determined basedon information on your Canada entry document.

5 If you move hereahead of your family, do not register any of your dependants untilthey arrive in : Alberta Health and Wellness does not consider theeffective dates or termination dates of other provincial/territorialor private Health plans when determining your eligibility date forAHCIP for Alberta Health CareInsurance Plan CoverageWhat about Health cards?Personal Health cards for you and your dependants will bemailed to you after your Application is processed. If you are newto Alberta from another province/territory and apply for AHCIP Coverage upon arrival in Alberta , your cards will be sent to youjust before your Coverage about premiums?AHCIP premiums are based on single (one person) or family (twoor more persons) Coverage . Quarterly premium statements will bemailed to your home address unless your Coverage is providedthrough your employer.

6 Options for paying your premiums areoutlined on the premium Health and Wellness has two premium assistance programsfor eligible low-income Albertans to reduce or eliminate AHCIP premiums. Information and applications for these programs areavailable on our website or by contacting 65 years of age and over and their eligible dependantsare not required to pay AHCIP premiums and also receive premiumfree Alberta Blue Cross Coverage . If you or your spouse/partnerare 65 years of age or older, we require proof of your age beforewe can provide you with these and WellnessAHC0102 (2005/05)Page 2 For more information or to obtain formsVisit our website at or contact our office between 8:15 and 4:30 Monday through Friday at theoffice addresses or telephone numbers on page 3 of this and returning Alberta residents who are applying for coverageunder the Alberta Health Care Insurance Plan (AHCIP) mustprovide documents to prove they are eligible for Coverage withtheir : You are not required to provide these documents if youare: moving from one AHCIP account to another, or a dependant must provide proof of the following to obtain AHCIP Coverage : Identity you are who you claim to be.

7 Legal entitlement to be in Canada you have the authorityset out under Canadian federal law to be in Canada; and Alberta residency you meet the definition of a resident(see page 1).To prove eligibility for AHCIP Coverage , applicants are requiredto submit a clear photocopy of: a document showing your identity - (must be photoidentification and is required for you and your spouse/partner, if applicable); a document showing legal entitlement to be in Canada -(required for you, your spouse/partner anddependants, if applicable); and a document showing proof of residency in Alberta -(must include name and address and is required foreither you or your spouse/partner, if applicable);or a combination of documents that meet all three tion tion tion tion VVVVV alidaalidaalidaalidaalidation Rtion Rtion Rtion Rtion Requirequirequirequirequirementsementsem entsementsementsPlease do not send originals as we cannot guarantee their safe chart below for examples of acceptable sYesYesYesYesYesYesYesCanadian immigration document Canadian passport Canadian citizenship certificate Permanent Resident CardFederal identification card Department of National Defence Royal Canadian Mounted Police First Nations/InuitAlberta Registries document Current Alberta driver s licence Current Alberta registries ID cardNon-Canadian passportIdentification card Municipal.

8 Provincial/territorial or federalgovernment employee card Student ID card Driver s licence from another province/territoryCanadian birth certificateCanada entry documentProvincial assistance program Current Income Support (social assistance) card Current AISH cardCurrent bills for Alberta residence (within the last 6 months) Utility Telephone Gas Cable or satelliteCurrent Alberta documents Residential property tax bill Residential land title Residential mortgage Residential rental agreement Residential lease agreement Residential Insurance Tenant Insurance Vehicle registrationType of DocumentCan the following be used asproof of identity?(must be photo identification)Can the following be used asproof of legal entitlement tobe in Canada?Can the following be used as proof ofAlberta residency?(must include name and address)NoNoNoNoNoNoNoYesYesYesYe sYe sNoNoNoNoNoNoNoNoNoColumn 1 Column 2 Column 3 AHC0102 (2005/05)Page 31.

9 Why are you applying for Alberta Health Care Insurance Plan(AHCIP) Coverage ? (please X all that apply)New resident of AlbertaReturning Alberta residentMarriage, separation or divorce (currently covered on an AHCIP account)Released from RCMP, Armed Forces or federal correctional instituteOther, specify:Section B - Alberta Residency (Please answer all questions)No longer a dependant on parent s AHCIP accountABCDEF2. Do you, your spouse/partner and dependants (if applicable)intend to reside in Alberta permanently?If you answered no, please explainand provide length of stay:Ye sNoSpouse/partnerApplicantDependantsYe sNoYe sNoDate of arrival in Canada (if applicable) Application forAlberta Health CareInsurance Plan CoverageAHC0102 All required documents (see page 2) must be submitted for this Application to be submit your Application and required documents to the address indicated provide personal information for your dependants on page AddressAlberta Health and WellnessPO Box 1360 Stn MainEdmonton AB T5J 2N3 Office Address10025 Jasper Ave Edmonton,or 727 7 Ave SW CalgaryTelephone(780) 427-1432 EdmontonToll free within Alberta at310-0000 then (780) 427-1432 Fax (780) (If not a Canadian citizen, include a clear photocopyof Canada entry document(s) with this Application .)

10 Other, specify status:CanadianLanded immigrant Citizenship or immigration statusPostal codeTitle ( Mr, Mrs, Miss, Ms, Dr, Rev, Sr)Last nameFirst nameBirthdate Male/Female Marital status (check one)Mailing addressCity/Town Postal codeLegal land description or physical address (if providing a Box or rural address)Section A1 - Applicant's personal information (Please print)SingleMarriedDivorcedSeparatedAdul t interdependentrelationshipWidowedMiddle name Province/TerritoryCity/TownProvince/Terr itoryOffice useYYYYMMDDFor Office Use OnlyArrived in Alberta from (Province/Territory/Country)Date permanent residence established in AlbertaYYYYMMDDY Y Y YMMDDP revious province/territory medical plan numberILRAILRSILRGS ection A2 - Spouse's/Partner's personal information(If not a Canadian citizen, include a clear photocopyof Canada entry document(s))