Request for Prescription and Non-Prescription Drugs 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient Information. Fill in the Health Benefits Cardholder Name, Alberta Personal Health Number, and Date of Birth.
3. Next, provide Health Professional Information. Include the name, profession, date, phone number, and an optional office stamp.
4. If applicable, fill in details for a Spouse or Child. Enter their name if the request is not for the cardholder.
5. In the Drug Product Requested section, list each drug on a separate line along with relevant medical conditions and whether this is a new or renewal request.
6. Provide any additional information that may support your exception request, such as other medical conditions or allergies.

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