Insurance Information Form

⚠️ IMPORTANT: Please bring a copy of your health card and any insurance cards with you to your appointment. This form helps us verify your coverage and submit claims accurately.

Patient Information

Patient Name: *

Date of Birth: *

Date: *

Alberta Health Care Coverage

Alberta Health Care Number: *

Version Code:

Expiry Date:

I confirm my Alberta Health Card is current and active *

I am new to Alberta (moved from another province/territory)

If new to Alberta, previous province/territory:

Date moved to Alberta:

Extended Health Benefits

I have extended health benefits/insurance coverage

Insurance Company Name:

Policy/Group Number:

Certificate/ID Number:

Effective Date:

Primary Policyholder Information

(Complete if patient is not the primary policyholder)

Primary Policyholder Name:

Date of Birth:

Relationship to Patient:

Employer/Plan Sponsor:

Policyholder Social Insurance Number:

Coverage Details

Prescription Drug Coverage

Vision Care Coverage

Dental Coverage

Physiotherapy/Massage Coverage

Medical Equipment Coverage

Ambulance Coverage

Annual Deductible Amount:

Co-payment Percentage:

Motor Vehicle Accident (MVA) Information

This visit is related to a motor vehicle accident

Date of Accident:

Claim Number:

Insurance Company (MVA):

Adjuster Name:

Workers' Compensation

This visit is related to a workplace injury

Date of Injury:

WCB Claim Number:

Employer at Time of Injury:

Billing Authorization

I authorize Clinic 1 Medical to bill my insurance company directly for covered services

I authorize Clinic 1 Medical to bill Alberta Health Care for insured services *

I understand that I am responsible for any charges not covered by insurance *

I will notify the clinic immediately of any changes to my insurance coverage *

Payment Information

Preferred Payment Method for Non-Covered Services:

Email receipts to me for insurance reimbursement

Email for Receipts:

Additional Information

Special instructions or notes about your coverage:

Acknowledgment and Consent

I certify that the information provided is accurate and complete *

I understand my financial responsibility for services rendered *

I consent to the use and disclosure of my personal health information for billing purposes *

Office Use Only

Health Card Verified:

Insurance Card Copied:

Staff Initials: