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AHS Connect Care Referral Form 21396 (Alberta)

A general referral form for sending consultation and e-Consult requests to Alberta Health Services clinics and specialists that work in Connect Care, the AHS clinical information system. Community providers without Connect Care access can use it to refer a patient. The form directs referrers to the Alberta Referral Directory for each service's criteria and where to send the referral.

Who completes it

The referring provider or their office completes the whole form, including patient, referral and management details, and the person completing it adds their name, designation, date and signature. The patient does not complete any part.

Submitting and payment

How to submit it
AHS says community providers do not need Connect Care access and should send referrals through existing methods such as fax or Netcare eReferral, with the Connect Care Provider Portal preferred where available. The Alberta Referral Directory gives each service's referral requirements and destination.

Good to know

  • Priority is routine or urgent, and type is consultation or e-Consult; the form also asks whether the patient's status is stable or worsening, or points to comments or an attached letter.
  • If the referral is not for a new problem, give the date it was previously referred, to whom, and the diagnosis or outcome of that earlier referral.
  • Processing requirements are checkboxes for what you attach: blood work, diagnostic imaging, consultant letters, discharge summaries, microbiology and pathology. Services in the referral directory may require specific items.
  • AHS states that community providers should receive referral status updates and a consult letter after each completed referral, and should not be asked to view documents in Connect Care.

Get the official form

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

Connect Care Referral

Official pagePDF

Fill it with Vero

Upload the fillable PDF 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 and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Do I need Connect Care access to refer a patient to AHS?

No. An AHS Connect Care memo says access is not required for making referrals to AHS, and referrals from community providers should go through existing methods, including fax or eReferral. Referral management then happens inside Connect Care, with status updates and consult letters sent back to the external referring provider by fax or mail.

Where do I send the Connect Care Referral form?

The form tells referrers to check the Alberta Referral Directory for criteria and where to send the referral. AHS describes the directory as the official source for referral-based services, listing each service's referral guidelines, forms and instructions, so a specific clinic may require its own form instead of, or alongside, form 21396.

What patient details does form 21396 ask for?

Legal and preferred names, PHN or ULI, date of birth, administrative gender (male, female, non-binary or prefer not to disclose (X), or unknown), address and phone, plus a legal guardian's name, relationship and phone where relevant. It also records the family physician and whether an interpreter is required, and in which language.