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.)
4
Page 1 of 2
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
z
z
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:
z
z
Birth date (yyyy/mm/dd)
Child's last name
1
2
3
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
Alberta Personal Health Number
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?
Page 1/2
Free Download
Child Health Benefit Application Form - Alberta PDF
Favor this template? Just fancy it by voting!
(0 Votes)
0.0
Related Forms
