AHC0109 (2004/11)
Page 1
Title (e.g. Mr. Mrs. Miss. Ms. Dr. Rev. Sr.)
First name
Last name as it appears on your personal health card
Middle name
Notification of Name
and Address Change
Personal health number
Complete Section A and only the section(s) where a change is required. If you are a new or returning resident
please contact Alberta Health and Wellness to obtain information on registering for coverage.
Before completing, please refer to the reverse side of this form.
–
Section A – Account holder’s personal information (Please print)
AHC0109
To mail correspondence:
Alberta Health and Wellness
PO Box 1360 Stn Main
Edmonton AB T5J 2N3
For service in person:
10025 Jasper Ave NW Edmonton,
or 727 7 Ave SW Calgary
To telephone:
427-1432 Edmonton
Toll-free within Alberta at
310-0000 then (780) 427-1432
To Fax: (780) 422-0102 Edmonton
To visit our Website:
www.health.gov.ab.ca
Section B – Account holder’s address change
New mailing address
City
Province/Territory
Country
Postal code
Home phone number
Work phone number
Extension
( )
( )
Section C – Account holder’s/Dependant name change
Personal health number
Correct spelling of last name, or change last name to
First name and/or middle name
–
•
If your name change is due to marriage, please complete Section D.
•
If you have more dependant name changes, please use a separate page.
•
If you are adding coverage for a spouse or partner who has arrived in Alberta from another country, you must include
copies of Canada entry documents.
Note:
Married couples must maintain coverage on one account. Whose account do you wish to maintain?
––––––––––––––––––––––––––––––––––––––––––––––––––––––
Section D - Spouse's/Partner's Information
Date of
First name
Title
Middle name
Previous last name (if applicable)
Will your spouse/partner reside in
Alberta permanently?
Previous medical plan number
Yes
Arrived in Alberta from (Province/Territory/Country)
No
Date of arrival in Alberta
Date of arrival in Canada
Spouse/Partner's last name
Canadian
La