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AHC2176: Alberta Out-of-Country Health Services Form

Alberta physicians and dentists use this application to ask the Out-of-Country Health Services Committee to pay for insured medical, oral surgical or hospital services abroad that aren't available in Canada. Patients cannot apply on their own. The Committee decides each case on the clinical evidence and the Out-of-Country Health Services Regulation, and elective care needs prior approval.

Who completes it

A licensed Alberta physician or dentist completes every section, including the evidence checklist and clinical documentation, and signs the Section H declaration accepting responsibility as the applying practitioner. Sections B and C hold the patient's and any parent or guardian's details.

Submitting and payment

How to submit it
Send the form and copies of clinical documentation to the Committee Chair by email, fax or mail. Once the file is complete, a decision is due within 60 business days, with written reasons sent within 20 business days of deciding.

Good to know

  • Wait times are not grounds for approval unless an appropriate specialist provides evidence they fall outside Alberta's standard of care. Confirmed appointments abroad aren't grounds either.
  • Don't attach invoices, receipts or cost information. The Committee doesn't cover meals, lodging, travel medical insurance, take-home drugs, equipment or supplies, or mental health and addiction services.
  • Services received before the Committee decides are at the patient's own risk. For urgent care, apply before treatment or seek reimbursement within 365 days afterward.
  • Section F asks you to confirm options were exhausted in Alberta and Canada, explain why this facility abroad was chosen, summarize options not pursued, and confirm follow-up care in Alberta.

Get the official form

Download the current version from the source each time; forms change without notice.

Out-of-Country Health Services application form

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Can a patient submit an out-of-country funding application in Alberta?

No. Only a licensed Alberta physician or dentist can submit the AHC2176 application and its clinical documentation, and patients can't self-refer or send documents themselves. By signing Section H, the practitioner accepts responsibility as the applying physician or dentist and endorses the out-of-country referral.

How do appeals work if the Committee refuses funding?

The patient, or the Alberta physician or dentist, can appeal to the separate Out-of-Country Health Services Appeal Panel. Written notice must reach the panel within 60 business days of the decision. The panel reviews whether the process and decision were fair and reasonable, cannot consider new information, and its decisions are final.

What clinical documentation should go with form AHC2176?

Section G lists copies of specialist or consultant findings and reports, diagnostic and laboratory reports, and clinical reports or referrals showing the history of services already exhausted in Canada. The documentation should also explain why the chosen program, facility or specialist abroad is needed. Financial documents are not accepted.