Application for Cost-Share Exemption for Hearing Aid Benefits for Seniors and Their Adult Dependents

Protected C (when completed)Alberta Aids to Daily Living (AADL) The information on this form is being collected and used by Alberta Health pursuant to sections 20, 21, 22 and 27 of the Health Information Act, sections 33(a) & (c) and 34 of the Freedom of Information and Protection of Privacy (FOIP) Act and the Alberta Aids to Daily Living and Extended Health Benefits Regulations for the purpose of determining eligibility for cost-share exemption for Alberta Aids to Daily Living equipment, supplies and services. If you have any questions about the collection of this information, you can contact the Alberta Aids to Daily Living Program at ATB Place North, 10025 Jasper Ave NW, Edmonton, Alberta T5J 1S6 Telephone: 780-427-0731 Fax: 780-422-0968.

This form is to be used for Alberta Aids to Daily Living (AADL) seniors hearing aid benefits and those hearing aid benefits previously provided by Special Needs Assistance for Seniors only. Please Note: Your cost-share exemption application will take 7 to 14 days to process. Please contact your vendor to confirm your status. Section A - Client's Personal Information

Name*

Title (Optional)First NameMiddle Name (Optional)Last Name

Date of Birth

Year*

Month*

Day*

Personal Health Number*

Address*

Mailing Address

Street Address Line 2

City or Town

Province*

Postal Code*

I authorize the Canada Revenue Agency to release information required from my tax file to Alberta Ministry of Health. The information will be relevant to and used solely for the purpose of determining and verifying my eligibility or that of my co-habiting partner or a child or adult dependent for whom | am the parent, legal guardian, Trustee or Attorney, for Cost-Share Exemption under the Alberta Aids to Daily Living and Extended Health Benefits Regulation (235/85), and the general administration and enforcement of the benefit program. This authorization is valid for the two taxation years prior to the year of signature of this consent, the current taxation year and for each subsequent consecutive taxation year for which assistance is requested. | understand that if I wish to withdraw this consent and eligibility for cost-share exemption, I may do so by writing to the Alberta Ministry of Health.

If this Section is not completed in its entirety, your application will not be processed and will be returned to you. To be completed by the client and their spouse/partner if over the age of 18. Please read, check each box and sign.

I have read the statement in Section B and consent to this authorization.

Yes I have read the statement

I certify that information given to me in this application is true and correct.

Yes the information is correct

Marital Status*

Applicant Name*

Applicant First NameApplicant Last Name

Applicant Date of Birth

Year*

Month*

Day*

Applicant Home Phone*

Applicant Work Phone

Applicant Social Insurance Number*

Signature*

Date yyyy/mm/dd*

Date

Name

Spouse/Partner First NameSpousePartner Last Name

Spouse/Partner Date of Birth

Year

Month

Day

Spouse/Partner Home Phone

Spouse/Partner Work Phone

Spouse/Partner Social Insurance Number

Date yyyy/mm/dd

Date

Signature

Please fill out and sign this section if you are the Parent/Guardian of the client named in Section A, if that client is under the age of 18 or if the client is a dependent adult listed on your Alberta Health Care Insurance Plan coverage.

Parent Guardian Name

Parent Guardian First NameParent Guardian Last Name

Parent Guardian Date of Birth

Year

Month

Day

Parent Guardian Home Phone

Parent Guardian Work Phone

Social Insurance Number

Date yyyy/mm/dd

Date

Signature*

Name

Parent Guardian / Spouse Partner First NameParent Guardian / Spouse Partner Last Name

Parent Guardian / Spouse Partner Date of Birth

Year

Month

Day

Parent Guardian / Spouse Partner Home Phone

Parent Guardian / Spouse Partner Work Phone

Parent Guardian / Spouse Partner Social Insurance Number

Date yyyy/mm/dd

Date

Signature*

Please fill out and sign this section if you are the Trustee/Power of Attorney of the client named in Section A

Trustee/Power of Attorney Name

Trustee/Power of Attorney First NameTrustee/Power of Attorney Last Name

Trustee/Power of Attorney Home Phone

Trustee/Power of Attorney Work Phone

Date yyyy/mm/dd

Date

Signature

I am (we are) responsible for this applicant as a:

Public TrusteePrivate TrusteeGuardian(s)Power of Attorney

To be completed by the Trustee/Power of Attorney if the client is over the age of 18 Attach supporting Trustee, Guardianship or Power of Attorney documents. Have you:

included your Personal Health Number (PHN)?included your Social Insurance Number (SIN)?included your spouse's information, if necessary?signed your form?attachedsupporting Trustee, Guardianship or Power of Attorney documents, if necessary?

Alberta Aids to Daily Living

ATB Place North

10025 Jasper Ave NW

Edmonton, AB T5J 1S6

Phone: 780-427-0731

Toll free, first dial: 310-0000, then 780-427-0731

Fax: 780-422-0968

https://www.alberta.ca/alberta-aids-to-daily-living.aspx

For Office Use Only

AHCIP

Family Composition

Cost-Share Exemption for Senior Hearing Aid Benefit

The AADL program assists eligible Albertans with a long-term disability, chronic illness or terminal illness, in maintaining independence in their community through the provision of basic medical equipment and supplies to meet their clinically assessed needs.

AADL clients above the qualifying income thresholds are subject to a cost-share component of 25% of the approved benefit amount to a maximum of $500 per individual/family per benefit year (July 1 to June 30)

You may qualify for cost-sharing exemption if your Taxable Income (line 26000 of your most recent income tax return) is:

$39,250 or less for a family with children.
$33,240 or less for a family with no children, or
$20,970 or less for a single person

If your Alberta Health Care Insurance Plan lists a spouse/partner, their taxable income must also be included in assessing your cost- share exemption application. Ensure that they have completed and signed Section C.

If you do not qualify for cost-share exemption through AADL, you may still receive maximum hearing aid funding through AADL if you are deemed to meet Special Needs Assistance for Seniors eligibility.

You may be deemed eligible for maximum funding if your total income (Line 15000 from your most recent tax return) is:

$29,630 or less for a single person, or
$48,120 or less for couples.

If your Alberta Health Care Insurance Plan lists a spouse/partner, their taxable income must also be included in assessing your cost- share exemption application. Ensure that they have completed and signed Section C. If you do not qualify for cost-share exemption, but due to more recent financial difficulty are unable to pay your cost-share portion, please complete a separate Temporary Cost-Share Exemption Application. Contact our office or obtain an application here:

Temporary Cost-Share Exemption Application form

You are NOT eligible to apply for cost-share exemption if you are:

a new or returning resident from outside Canada, who has not yet lived in Alberta for 12 consecutive months.
exempt from paying income tax for religious, charitable or communal reasons.
a student from outside Canada who is temporarily in Canada.

Trustee, Guardianship or Power of Attorney

Please ensure that you attach copies of all relevant documents granting your rights of trusteeship, guardianship or power of attorney.

Definitions

Spouse

A spouse is a person to whom you are legally married.

Adult Interdependent Partner

An adult interdependent partner is a person who lives with another person in a relationship of interdependence:

for a continuous period of not less than three years;
of some permanence if, as a result of the relationship, the partners have a child by birth or adoptions; or
the partners have entered into an adult interdependent partner agreement as provided in the Adult Interdependent Relationship Act.

Section A - Client's Personal Information

Section B - Consent

Section C - Declaration