Form Schema - gpt-4.1-mini-2025-04-14
{
"title": "Alberta Health Care Insurance Plan - Notice of Change/Addition",
"fields": [
{
"name": "last_name",
"type": "text",
"label": "Last Name"
},
{
"name": "first_name",
"type": "text",
"label": "First Name"
},
{
"name": "middle_name",
"type": "text",
"label": "Middle Name"
},
{
"name": "personal_health_number",
"type": "text",
"label": "Personal Health Number"
},
{
"name": "new_last_name",
"type": "text",
"label": "New Last Name (If applicable. Proof required)"
},
{
"name": "date_of_birth",
"type": "date",
"label": "Date of Birth (yyyy-mm-dd)"
},
{
"name": "gender_male",
"type": "text",
"label": "Gender - Male"
},
{
"name": "gender_female",
"type": "text",
"label": "Gender - Female"
},
{
"name": "phone_number",
"type": "text",
"label": "Phone Number"
},
{
"name": "mailing_apt_unit",
"type": "text",
"label": "Mailing Address - Apt./Unit #"
},
{
"name": "mailing_street",
"type": "text",
"label": "Mailing Address - Street"
},
{
"name": "new_address_checkbox",
"type": "text",
"label": "Check if this is a new address"
},
{
"name": "mailing_city_town",
"type": "text",
"label": "Mailing Address - City/Town"
},
{
"name": "mailing_province",
"type": "text",
"label": "Mailing Address - Province"
},
{
"name": "mailing_postal_code",
"type": "text",
"label": "Mailing Address - Postal Code"
},
{
"name": "home_apt_unit",
"type": "text",
"label": "Home Address - Apt./Unit #"
},
{
"name": "home_street_or_land_description",
"type": "text",
"label": "Home Address - Street or legal land description (if different from mailing address)"
},
{
"name": "home_city_town",
"type": "text",
"label": "Home Address - City/Town"
},
{
"name": "home_province",
"type": "text",
"label": "Home Address - Province"
},
{
"name": "home_postal_code",
"type": "text",
"label": "Home Address - Postal Code"
},
{
"name": "spouse_last_name",
"type": "text",
"label": "Spouse/Adult Interdependent Partner Last Name (Proof of identity required)"
},
{
"name": "spouse_previous_last_name",
"type": "text",
"label": "Previous Last Name(s) (if applicable)"
},
{
"name": "spouse_personal_health_number",
"type": "text",
"label": "Personal Health Number (if known)"
},
{
"name": "spouse_first_name",
"type": "text",
"label": "Spouse First Name"
},
{
"name": "spouse_middle_name",
"type": "text",
"label": "Spouse Middle Name"
},
{
"name": "spouse_date_of_birth",
"type": "date",
"label": "Spouse Date of Birth (yyyy-mm-dd)"
},
{
"name": "spouse_gender_male",
"type": "text",
"label": "Spouse Gender - Male"
},
{
"name": "spouse_gender_female",
"type": "text",
"label": "Spouse Gender - Female"
},
{
"name": "spouse_citizen_yes",
"type": "text",
"label": "Is your spouse/adult interdependent partner a Canadian citizen? - Yes"
},
{
"name": "spouse_citizen_no",
"type": "text",
"label": "Is your spouse/adult interdependent partner a Canadian citizen? - No"
},
{
"name": "spouse_permanent_resident",
"type": "text",
"label": "Permanent Resident"
},
{
"name": "spouse_study_permit",
"type": "text",
"label": "Study Permit"
},
{
"name": "spouse_work_permit",
"type": "text",
"label": "Work Permit"
},
{
"name": "spouse_visitor_record",
"type": "text",
"label": "Visitor Record"
},
{
"name": "spouse_other_status",
"type": "text",
"label": "Other"
},
{
"name": "spouse_status_issue_date",
"type": "date",
"label": "Status Issue Date (yyyy-mm-dd)"
},
{
"name": "spouse_status_expiry_date",
"type": "date",
"label": "Status Expiry Date (yyyy-mm-dd)"
},
{
"name": "spouse_ahcip_no",
"type": "text",
"label": "Does your spouse/adult interdependent partner currently have, or have they previously had, AHCIP coverage? - No"
},
{
"name": "spouse_ahcip_yes",
"type": "text",
"label": "Does your spouse/adult interdependent partner currently have, or have they previously had, AHCIP coverage? - Yes"
},
{
"name": "spouse_previous_ahcip_number",
"type": "text",
"label": "Provide their previous Alberta Personal Health Number (if known)"
},
{
"name": "reason_marriage_adult_interdependent_partnership",
"type": "text",
"label": "Why are you adding your spouse/adult interdependent partner to your account? (Check all that apply) - Marriage or Adult Interdependent Partnership"
},
{
"name": "reason_date_of_event",
"type": "date",
"label": "Date of Event (yyyy-mm-dd)"
},
{
"name": "reason_new_or_returning",
"type": "text",
"label": "New or Returning to Alberta"
},
{
"name": "reason_released_military",
"type": "text",
"label": "Released from Military"
},
{
"name": "reason_released_federal_institution",
"type": "text",
"label": "Released from Federal Institution"
},
{
"name": "reason_date_released",
"type": "date",
"label": "Date Released (yyyy-mm-dd)"
},
{
"name": "spouse_date_arrived_alberta",
"type": "date",
"label": "Date they arrived in Alberta (yyyy-mm-dd)"
},
{
"name": "spouse_date_decided_permanent",
"type": "date",
"label": "Date they decided to live in Alberta permanently, if different from date of arrival (yyyy-mm-dd)"
},
{
"name": "spouse_arrival_place",
"type": "text",
"label": "Where did they arrive from? (Country/Province/Territory)"
},
{
"name": "spouse_previous_health_number",
"type": "text",
"label": "Previous Canadian provincial/territorial health number/medical plan number"
},
{
"name": "spouse_intend_stay_yes",
"type": "text",
"label": "Does your spouse/adult interdependent partner intend to stay in Alberta for 12 months or longer? - Yes"
},
{
"name": "spouse_intend_stay_no",
"type": "text",
"label": "Does your spouse/adult interdependent partner intend to stay in Alberta for 12 months or longer? - No"
},
{
"name": "spouse_intend_stay_explanation",
"type": "text",
"label": "Please explain why and state how long they stay will be"
},
{
"name": "declaration_date",
"type": "date",
"label": "Date"
},
{
"name": "registrant_signature",
"type": "text",
"label": "Registrant Signature"
},
{
"name": "spouse_signature",
"type": "text",
"label": "Spouse/Adult Interdependent Partner Signature"
},
{
"name": "dependant_last_name",
"type": "text",
"label": "Dependant Last Name"
},
{
"name": "dependant_first_name",
"type": "text",
"label": "Dependant First Name"
},
{
"name": "dependant_middle_name",
"type": "text",
"label": "Dependant Middle Name"
},
{
"name": "dependant_personal_health_number",
"type": "text",
"label": "Dependant Personal Health Number (if known)"
},
{
"name": "dependant_date_of_birth",
"type": "date",
"label": "Dependant Date of Birth (yyyy-mm-dd)"
},
{
"name": "dependant_gender_male",
"type": "text",
"label": "Dependant Gender - Male"
},
{
"name": "dependant_gender_female",
"type": "text",
"label": "Dependant Gender - Female"
},
{
"name": "dependant_date_of_dependency",
"type": "date",
"label": "Date of Dependency (yyyy-mm-dd)"
},
{
"name": "dependant_relationship",
"type": "text",
"label": "Relationship to dependant (e.g. parent, guardian)"
},
{
"name": "dependant_citizen_yes",
"type": "text",
"label": "Is your dependant a Canadian citizen? - Yes"
},
{
"name": "dependant_citizen_no",
"type": "text",
"label": "Is your dependant a Canadian citizen? - No"
},
{
"name": "dependant_permanent_resident",
"type": "text",
"label": "Permanent Resident"
},
{
"name": "dependant_study_permit",
"type": "text",
"label": "Study Permit"
},
{
"name": "dependant_work_permit",
"type": "text",
"label": "Work Permit"
},
{
"name": "dependant_visitor_record",
"type": "text",
"label": "Visitor Record"
},
{
"name": "dependant_other_status",
"type": "text",
"label": "Other"
},
{
"name": "dependant_status_issue_date",
"type": "date",
"label": "Status Issue Date (yyyy-mm-dd)"
},
{
"name": "dependant_status_expiry_date",
"type": "date",
"label": "Status Expiry Date (yyyy-mm-dd)"
},
{
"name": "dependant_ahcip_no",
"type": "text",
"label": "Does your dependant currently have, or have they previously had, AHCIP coverage? - No"
},
{
"name": "dependant_ahcip_yes",
"type": "text",
"label": "Does your dependant currently have, or have they previously had, AHCIP coverage? - Yes"
},
{
"name": "dependant_previous_ahcip_number",
"type": "text",
"label": "Provide your dependant's previous Alberta Personal Health Number (if known)"
},
{
"name": "dependant_previous_registered_name",
"type": "text",
"label": "Name your dependant was previously registered under (if known)"
},
{
"name": "dependant_reason_birth",
"type": "text",
"label": "Why are you adding this dependant to your AHCIP coverage? - Birth"
},
{
"name": "dependant_reason_birth_in_alberta",
"type": "text",
"label": "Why are you adding this dependant to your AHCIP coverage? - Birth in Alberta"
},
{
"name": "dependant_reason_adoption_guardian_custody",
"type": "text",
"label": "Why are you adding this dependant to your AHCIP coverage? - Adoption/Guardian/Custody (Legal documents required)"
},
{
"name": "dependant_reason_other",
"type": "text",
"label": "Why are you adding this dependant to your AHCIP coverage? - Other (e.g. student)"
},
{
"name": "dependant_reason_date_of_event",
"type": "date",
"label": "Date of Event (yyyy-mm-dd)"
},
{
"name": "dependant_arrival_place",
"type": "text",
"label": "Where did your dependant arrive from? (Country/Province/Territory)"
},
{
"name": "dependant_date_arrived_canada",
"type": "date",
"label": "Date your dependant arrived in Canada if arrived from outside Canada (yyyy-mm-dd)"
},
{
"name": "dependant_date_arrived_alberta",
"type": "date",
"label": "Date your dependant arrived in Alberta (yyyy-mm-dd)"
},
{
"name": "dependant_date_decided_permanent",
"type": "date",
"label": "Date your dependant decided to live in Alberta permanently, if different from date of arrival (yyyy-mm-dd)"
},
{
"name": "dependant_previous_health_number",
"type": "text",
"label": "Previous Canadian provincial/territorial health number/medical plan number"
},
{
"name": "dependant_intend_stay_yes",
"type": "text",
"label": "Does your dependant intend to stay in Alberta for 12 months or longer? - Yes"
},
{
"name": "dependant_intend_stay_no",
"type": "text",
"label": "Does your dependant intend to stay in Alberta for 12 months or longer? - No"
},
{
"name": "dependant_intend_stay_explanation",
"type": "text",
"label": "Please explain why and state how long your dependant's stay will be"
},
{
"name": "card_requested_yes",
"type": "text",
"label": "Card Requested - Yes"
},
{
"name": "card_requested_no",
"type": "text",
"label": "Card Requested - No"
}
]
}