Note that all sections must be filled out in to avoid delay with your request. Please allow 7-10 business days for Alberta Health to process your request.
You are able to apply for an unlimited number of BAs, so if you are applying for new one will not affect your existing BAs.
- You can either apply with your Practitioner ID or with the Clinic ULI
- The "Name" will be the BA (Business Arrangement) contract holder, which can be a person or an organization/professional corporation
- The Effective Date, is the date when this arrangement is to start, you will want it to encompass any back dated invoices that may need to be sent through ClinicAid. If an invoice is submitted with a service date outside of your BA's effective date, it will reject with code 37 - invalid BA.
- If you are making changes to an existing BA or are ending a BA you will need to add a date as well
- If you are requesting direct deposit a chequing account you MUST attach a VOID cheque with your request
- If you are requesting direct deposit to a savings account you MUST attach documentation from your financial institution which includes the bank number, branch transit number and the account number
If you are submitting your request via fax, please ensure all the information is legible, otherwise your request may be delayed.
Suppress Statement of Assessment production: by checking off "Yes" you will receive a paper statement (ClinicAid provides you with an electronic copy).
Skills: Practitioners with multiple skills must designate a default skill for claim submission purposes.
(When the Skill Code field on a claim to the AHCIP is left blank, the claim is automatically processed using the default skill you choose)
For Section C, you need to complete all the information for the request to be considered as valid, only the physician applying for the BA will need to sign the form, unless they are joining an existing BA, in which case, that BA contract holder would also have to sign.
Note, ClinicAid does not need to sign this form.
For further assistance in completing your request, you contact Alberta Health at 780-422-1522 in Edmonton, or toll-free within Alberta at 310-0000.
All forms can either be faxed to 780-422-3552 or mailed to Alberta Health and Wellness:
Professional and Facility Management Unit
PO Box 1360 Station Main
Edmonton AB T5J 2N3