Medicaid Change Of Information Form

Date:

Statement Of Benefits Paid

PECOS Enrollment Tutorial Change of Information for an Individual Provider

A Statement of Benefits Paid is a list of physician services paid for by the AHCIP on your behalf during a specific period. It includes the date and general type of service, physician name and the amount that was paid to the physician.

The requested SOBP is sent directly to the individual or their authorized representative.

Hospital services do not appear on the SOBP. These may be requested directly from the hospital.

Replacing A Photo Health Card

How you replace a photo health card depends on whether it is expired or not and whether your personal information has changed or not.

You must visit a ServiceOntario centre to replace an unexpired photo health card if your name or address has changed.

If your name and address has not changed, you can replace an unexpired lost, stolen or damaged photo health card by calling ServiceOntario at .

To replace an expired photo health card after the renewal date, you must visit a ServiceOntario centre.

Bring two separate identification documents from the list of qualifying identification documents :

  • an original, printed or digital/electronic one that proves you live in Ontario
  • an original one that confirms your identity
  • If your Canadian Citizenship or immigration status has changed since you got your current health card, you also need to bring your most recent Citizenship or immigration document

    How To Order An Sobp

    Current year

    There is no cost for an SOBP for the most recent benefit year to the current year to date.

    To request a current SOBP:

    Download and complete the Request for Statement of Benefits Paid form and mail the completed form to the AHCIP office.

    Or, place an order using the automated phone system:

    • Toll free: before the phone number

    Previous years

    An SOBP can be requested back to October 1, 1993. There is a fee of $25 plus GST per request for individuals ordering a personal SOBP directly.

    Families ordering for more than one person on the same AHCIP account pay only $26.25 for everyone.

    To request an SOBP from previous years:

  • Download and compete the Request for Statement of Benefits Paid form.
  • Mail the completed form with your payment. Only cheques or money orders are accepted, payable to Government of Alberta.
  • Third-party requests

    If a third-party such as law firm or insurance company wishes to request an SOBP on behalf of an Albertan, contact Alberta Health by emailing .

    Effective January 1, 2020, the fee for third-party SOBP requests is $75 .

    Read Also: How Many Levels Of Medicaid Are There

    Apply For Health Care Coverage

    PDF form issues

    Fillable PDF forms do not open properly on some mobile devices and web browsers. To fill in and save the form:

  • Save the PDF form to your computer click or right-click the link and download the form.
  • Open the PDF form with Adobe Reader. Fill it in and save it.
  • Find out how to claim for benefits through Alberta Blue Cross.

    Instructions For Opening A Form

    FREE 32+ Change Form Examples in PDF
    Some forms cannot be viewed in a web browser and must be opened in Adobe Reader on your desktop system.
    • To provide clients a form that lists their reporting requirements.
    • To provide clients a form to report changes in their circumstances.
    • To provide Texas Health and Human Services Commission office staff a form to record information reported by clients about changes in their circumstances.
    • To advise the individual that the advisor can explain what type of proof is required for a reported change.
    • To provide clients with a receipt of the change they reported.

    Read Also: Is Obamacare And Medicaid The Same Thing

    Red And White Health Card

    To replace a lost, stolen or damaged red and white Ontario health card, you must visit a ServiceOntario centre with a completed Registration for Ontario Health Insurance Coverage form.

    You will need to bring three separate identification documents from the list of qualifying identification documents :

  • an original one that proves your Canadian citizenship or OHIP-eligible immigration status
  • an original, printed or digital/electronic one that proves you live in Ontario
  • an original one that confirms your identity
  • You will receive a new photo health card in 4 to 6 weeks.

    Death Of A Family Member

    To cancel a family members health card following their death, please visit any ServiceOntario centre.

    Bring the following with you:

    • the health card
    • This can be a death certificate from the funeral home or a certificate from ServiceOntario

    If you do not have a death certificate, you can complete a Change of Information Form.

    Read Also: Does Medicaid Cover All Pregnancy Costs

    Change A Name On A Health Card

    To change your name on your health card, you must visit a ServiceOntario centre.

    Bring a completed Change of Information form and an original copy of one of the following documents:

    For a first name or middle name change

    • Canadian birth certificate
    • Canadian change of name certificate
    • citizenship/immigration status document in the name requested

    For a last name change

    • certificate of marriage
    • certified copy of statement of marriage
    • Canadian change of name certificate
    • a Record of Marriage
    • notarized affidavit
    • divorce certificate
    • Citizenship/immigration status document in the name requested
    • Citizenship/immigration status document for the name currently on your health card and a marriage document audit trail backward to the name requested
    • certified copy of the court order for a change in name
    • Adoption Certificate

    If you have a red and white health card, you must also provide three original documents to prove citizenship or eligible immigration status, Ontario residency and identity. Check the Ontario Health Coverage Document List for acceptable documents.

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