Income Assessment Form For Edmonton Zone Ambulatory Community Physiotherapy printable pdf download

Income Assessment Form For Edmonton Zone Ambulatory Community Physiotherapy

Income Assessment Form

for Edmonton Zone Ambulatory

Community Physiotherapy

Completion Instructions:

To be eligible for further Alberta Health Services (AHS) Allied Health – Edmonton Zone funded

physiotherapy treatments based upon your income status; you will need to provide proof to your

physiotherapy clinic that you are currently covered by one of the following government subsidy

programs (Section A). If you do not participate in any of the programs listed in Section A, go to

Section B or C.

If you meet one of the low income qualifications, you will receive up to 4 more funded visits paid by

AHS, Allied Health – Edmonton Zone. You may receive further visits if your case is approved by

Allied Health – Edmonton Zone.

Client Information

(Print clearly)

Last Name:

First Name:

Alberta’s Personal Health Number (PHN):

What is your family size (include yourself, spouse/common-law partner and dependent children)?

Section A – Government Subsidy Program

If you receive assistance from one of the government programs listed below, fill out Section A

only. Place a check beside the government program(s) from which you receive assistance. In

order to be eligible for further funded physiotherapy, provide proof of participation in the program to

the physiotherapy clinic.

Alberta Seniors Benefit (must be receiving Monthly Cash Benefit)

Alberta Works – Adult Health Benefit: extended health benefit for people leaving AISH or Alberta Works

Alberta Works – Alberta Child Health Benefit Plan

Alberta Works – Alberta Income Support

Assured Income for the Severely Handicapped (AISH)

Federal Guaranteed Income Supplement (GIS) for Seniors

Special Needs Assistance for Seniors (Alberta)

Student Aid Alberta (student loans)

I verify that valid documentation of participation in one of the above government programs has been

presented to me.

Physical Therapy Clinic Staff Signature

Date (dd/mmm/yyyy)

Effective September 1, 2014

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Income Assessment Form For Edmonton Zone Ambulatory Community Physiotherapy