Child Health Benefit Application Form - Alberta

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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1
2
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
X
Date (yyyy/mm/dd) Spouse/Partner's signature (if applicable)
X
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)
X
Date (yyyy/mm/dd)My signature
X
HRE2939Web (2006/03)
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Child Health Benefit Application Form - Alberta PDF

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