AEHB3487 (2015/12) Page 1 of 2

THINGS YOU NEED TO KNOW ABOUT REQUESTING A HEALTH BENEFITS EXCEPTION

Health benefits provided by Alberta Health are controlled by Regulations and Agreements between the Minister of Human Services and the Minister of Health and professional groups, such as the Alberta Dental Association and College. In most situations the regulations do not allow anyone but the Health Benefits Exception Committee (HBEC) to give a health benefit not listed in the agreements.

If you require a health benefit (prescription or non-prescription drug or nutritional product, diabetic supply, optical benefit, dental benefit, or ambulance service) not covered on your health benefits card, you may request review by the Health Benefits Exception Committee (HBEC) or by the AISH Program.

WHAT YOU NEED TO DO

l Complete the Request for a Health Benefit Exception form, and sign and date it.

l If you are requesting a drug or nutritional product, have your doctor complete a Request for Prescription and Non-prescription Drugs form. You can get this form from your worker or print it from http://humanservices.alberta.ca/financial-support/2073.html..

l If you are requesting an optical benefit, have your optical services provider complete a Request for Optical Services form. You can get this form from your worker or print it from http://humanservices.alberta.ca/financial-support/2073.html.

l If you are requesting a dental benefit, ask your dentist for a copy of the Standard Dental Claim form that gives the details of the dental procedures requested.

l Submit the forms and other information to the applicable office shown below. Your worker or other government staff person will consider the request, and send all documents to be considered by the HBEC or the AISH Program.

REVIEW BY THE HEALTH BENEFITS EXCEPTION COMMITTEE

The HBEC provides a fair and neutral review of health benefit requests. Decisions are made based on laws, policy, the agreements, and the information you submit to support the medical need for the health benefit you are requesting. Staff review written material submitted, and do not hold an in-person hearing. A staff person may contact your medical or health care provider by phone or letter to request further information if needed to make a decision.

After the HBEC makes a decision, you will be notified in writing. This includes the reasons for the decision. The decision is final and cannot be appealed; however, if new medical information is provided, your request will be reconsidered and a new decision will be sent to you in writing.

WHERE TO SEND THE REQUEST FOR A HEALTH BENEFIT EXCEPTIONPlease submit the completed and signed Request for a Health Benefit Exception form and other documents to the program that is providing your health benefits, as below:

■ All drugs and nutritional Products requested must have a Drug Identification Number or Natural Product Number assigned to them by Health Canada.

Income Support or AISH Mail or drop off the request to the office where your financial worker is.

Learners

Learner Income Support Centre Box 17000 Stn Main

Edmonton, AB T5J 4R4 or fax 310-000, then 780-415-9947 or in Edmonton, 780-415-9947

Alberta Adult Health Benefit or Alberta Child Health Benefit

programs ONLY

Alberta Human Services Health Benefits Contact Centre P O Box 2222

Edmonton, AB T5J 5H3 or fax 310-0000, then 780-415-8386 or in Edmonton, 780-415-8386

File Section 4AEHB3487 (2015/12) Page 2 of 2

Request for a Health Benefit Exception

The information on this form is collected under the authority of the Health Information Act (sections 20, 21, 22), the Freedom of Information and Protection of Privacy Act (sections 33 and 34), the Assured Income for the Severely Handicapped Act (section 5), and the Income and Employment Supports Act (section 8) for the purpose of determining or verifying eligibility to receive a health benefit. If you have any questions regarding the collection or use of the this information, please contact an Information Officer at Alberta Health, PO Box 1360 Station Main, Edmonton, AB, T5J 2N3 or toll-free in Alberta by dialing 310-0000 followed by 780-427-1432.

Health Benefits Exception Committee/AISH Health Benefits Exception

Client Information

Income Support (IS) Health BenefitsAssured Income for the Severely Handicapped (AISH) Health BenefitsAlberta Adult Health Benefit (AAHB)Alberta Child Health Benefit (ACHB)

Personal Health Number (if ACHB or AAHB):

Office/Unit/Caseload File Number

Worker's Name

Date (yyyy-mm-dd)

If client cannot sign, was verbal consent obtained for the HBEC or the AISH Program to contact health providers? Yes No

Date of Last Eye Exam (for optical benefits) (yyyy-mm-dd)

Date Last Eyeglasses Provided (for optical benefits) (yyyy-mm-dd)

Date of Last Dentures Provided (for denturist benefits) (yyy-mm-dd)

For Optical and Denturist Benefits, repayment discussed?

Yes No

Health Benefit Cardholder's Last Name First Name Telephone Number

Address Street/PO Box City/Town/Municipality Postal Code

Worker's Phone Number

1. What health benefit are you requesting?

Full Name of spouse/child if request is not for yourself Personal Health Number of spouse/childDate of Birth (yyyy-mm-dd) - -

2. Why do you need this health benefit? (Attach additional pages if you need more space to describe your situation)

Attach letters from your medical doctor or other documents to support your request

I consent to Alberta Health, Alberta Human Services, and the Health Benefits Exception Committee contacting health service providers, my worker, and/or the benefit administrators to obtain or provide additional information if required regarding my health needs and/or health benefits coverage as they relate to this request.

Date (yyyy-mm-dd) Health Benefits Cardholder's Signature

Where will you get the requested item (e.g., name of your pharmacy, optometrist, dentist/denturist) Telephone Number

City/Town/MunicipalityAddress Street/PO Box

Please keep a copy of this form and any attachments for your records.

Postal Code