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",
"options": null
},
{
"name": "first_name",
"type": "text",
"label": "First Name",
"options": null
},
{
"name": "middle_name",
"type": "text",
"label": "Middle Name",
"options": null
},
{
"name": "personal_health_number",
"type": "text",
"label": "Personal Health Number",
"options": null
},
{
"name": "new_last_name",
"type": "text",
"label": "New Last Name (If applicable. Proof required)",
"options": null
},
{
"name": "date_of_birth",
"type": "date",
"label": "Date of Birth (yyyy-mm-dd)",
"options": null
},
{
"name": "phone_number",
"type": "text",
"label": "Phone Number",
"options": null
},
{
"name": "gender",
"type": "radio",
"label": "Gender",
"options": [
"Male",
"Female"
]
},
{
"name": "mailing_apt_unit",
"type": "text",
"label": "Mailing Address Apt./Unit #",
"options": null
},
{
"name": "mailing_street",
"type": "text",
"label": "Mailing Address Street",
"options": null
},
{
"name": "is_new_address",
"type": "checkbox",
"label": "Check if this is a new address",
"options": null
},
{
"name": "mailing_city_town",
"type": "text",
"label": "Mailing Address City/Town",
"options": null
},
{
"name": "mailing_province",
"type": "text",
"label": "Mailing Address Province",
"options": null
},
{
"name": "mailing_postal_code",
"type": "text",
"label": "Mailing Address Postal Code",
"options": null
},
{
"name": "home_apt_unit",
"type": "text",
"label": "Home Address Apt./Unit #",
"options": null
},
{
"name": "home_street_legal_desc",
"type": "text",
"label": "Home Address Street or legal land description (if different from mailing address)",
"options": null
},
{
"name": "home_city_town",
"type": "text",
"label": "Home Address City/Town",
"options": null
},
{
"name": "home_province",
"type": "text",
"label": "Home Address Province",
"options": null
},
{
"name": "home_postal_code",
"type": "text",
"label": "Home Address Postal Code",
"options": null
},
{
"name": "spouse_last_name",
"type": "text",
"label": "Last Name (Spouse/Adult Interdependent Partner)",
"options": null
},
{
"name": "spouse_previous_last_name",
"type": "text",
"label": "Previous Last Name(s) (if applicable) (Spouse)",
"options": null
},
{
"name": "spouse_personal_health_number",
"type": "text",
"label": "Personal Health Number (if known) (Spouse)",
"options": null
},
{
"name": "spouse_first_name",
"type": "text",
"label": "First Name (Spouse)",
"options": null
},
{
"name": "spouse_middle_name",
"type": "text",
"label": "Middle Name (Spouse)",
"options": null
},
{
"name": "spouse_date_of_birth",
"type": "date",
"label": "Date of Birth (yyyy-mm-dd) (Spouse)",
"options": null
},
{
"name": "spouse_gender",
"type": "radio",
"label": "Gender (Spouse)",
"options": [
"Male",
"Female"
]
},
{
"name": "spouse_canadian_citizen",
"type": "radio",
"label": "Is your spouse/adult interdependent partner a Canadian citizen?",
"options": [
"Yes",
"No"
]
},
{
"name": "spouse_status",
"type": "select",
"label": "If No, Spouse Status",
"options": [
"Permanent Resident",
"Study Permit",
"Work Permit",
"Visitor Record",
"Other"
]
},
{
"name": "spouse_status_issue_date",
"type": "date",
"label": "Issue Date (yyyy-mm-dd) (Spouse Status)",
"options": null
},
{
"name": "spouse_status_expiry_date",
"type": "date",
"label": "Expiry Date (yyyy-mm-dd) (Spouse Status)",
"options": null
},
{
"name": "spouse_had_ahcip_coverage",
"type": "radio",
"label": "Does your spouse/adult interdependent partner currently have, or have they previously had, AHCIP coverage?",
"options": [
"No",
"Yes"
]
},
{
"name": "spouse_previous_ahcip_number",
"type": "text",
"label": "Previous Alberta Personal Health Number (Spouse)",
"options": null
},
{
"name": "spouse_adding_reason",
"type": "checkbox",
"label": "Why are you adding your spouse/adult interdependent partner to your account? (Check all that apply)",
"options": [
"Marriage or Adult Interdependent Partnership",
"Date of Event (yyyy-mm-dd)",
"New or Returning to Alberta",
"Released from Military",
"Released from Federal Institution"
]
},
{
"name": "spouse_date_of_event",
"type": "date",
"label": "Date of Event (yyyy-mm-dd) (Spouse)",
"options": null
},
{
"name": "spouse_date_released",
"type": "date",
"label": "Date Released (yyyy-mm-dd) (Spouse)",
"options": null
},
{
"name": "spouse_arrival_place",
"type": "text",
"label": "Where did your spouse/adult interdependent partner arrive from? (Country/Province/Territory)",
"options": null
},
{
"name": "spouse_arrival_date_canada",
"type": "date",
"label": "Date they arrived in Canada, if arrived from outside Canada (yyyy-mm-dd)",
"options": null
},
{
"name": "spouse_arrival_date_alberta",
"type": "date",
"label": "Date they arrived in Alberta (yyyy-mm-dd)",
"options": null
},
{
"name": "spouse_permanent_residence_date",
"type": "date",
"label": "Date they decided to live in Alberta permanently, if different from date of arrival (yyyy-mm-dd)",
"options": null
},
{
"name": "spouse_previous_health_plan_number",
"type": "text",
"label": "Previous Canadian provincial/territorial health number/medical plan number (Spouse)",
"options": null
},
{
"name": "spouse_intends_stay_12_months",
"type": "radio",
"label": "Does your spouse/adult interdependent partner intend to stay in Alberta for 12 months or longer?",
"options": [
"Yes",
"No"
]
},
{
"name": "spouse_stay_explanation",
"type": "text",
"label": "Please explain why and state how long they stay will be (Spouse)",
"options": null
},
{
"name": "declaration_date",
"type": "date",
"label": "Date",
"options": null
},
{
"name": "registrant_signature",
"type": "text",
"label": "Registrant Signature",
"options": null
},
{
"name": "spouse_signature",
"type": "text",
"label": "Spouse/Adult Interdependent Partner Signature",
"options": null
},
{
"name": "dependant_last_name",
"type": "text",
"label": "Dependant Last Name",
"options": null
},
{
"name": "dependant_first_name",
"type": "text",
"label": "Dependant First Name",
"options": null
},
{
"name": "dependant_middle_name",
"type": "text",
"label": "Dependant Middle Name",
"options": null
},
{
"name": "dependant_personal_health_number",
"type": "text",
"label": "Personal Health Number (if known) (Dependant)",
"options": null
},
{
"name": "dependant_date_of_birth",
"type": "date",
"label": "Date of Birth (yyyy-mm-dd) (Dependant)",
"options": null
},
{
"name": "dependant_gender",
"type": "radio",
"label": "Gender (Dependant)",
"options": [
"Male",
"Female"
]
},
{
"name": "dependant_date_of_dependency",
"type": "date",
"label": "Date of Dependency (yyyy-mm-dd)",
"options": null
},
{
"name": "dependant_relationship",
"type": "text",
"label": "Relationship to dependant (e.g. parent, guardian)",
"options": null
},
{
"name": "dependant_canadian_citizen",
"type": "radio",
"label": "Is your dependant a Canadian citizen?",
"options": [
"Yes",
"No"
]
},
{
"name": "dependant_status",
"type": "select",
"label": "If No, Dependant Status",
"options": [
"Permanent Resident",
"Study Permit",
"Work Permit",
"Visitor Record",
"Other"
]
},
{
"name": "dependant_status_issue_date",
"type": "date",
"label": "Issue Date (yyyy-mm-dd) (Dependant Status)",
"options": null
},
{
"name": "dependant_status_expiry_date",
"type": "date",
"label": "Expiry Date (yyyy-mm-dd) (Dependant Status)",
"options": null
},
{
"name": "dependant_had_ahcip_coverage",
"type": "radio",
"label": "Does your dependant currently have, or have they previously had, AHCIP coverage?",
"options": [
"No",
"Yes"
]
},
{
"name": "dependant_previous_ahcip_number",
"type": "text",
"label": "Previous Alberta Personal Health Number (Dependant)",
"options": null
},
{
"name": "dependant_previous_registered_name",
"type": "text",
"label": "Name your dependant was previously registered under (if known)",
"options": null
},
{
"name": "dependant_adding_reason",
"type": "checkbox",
"label": "Why are you adding this dependant to your AHCIP coverage? (check all that apply)",
"options": [
"Birth",
"Birth in Alberta",
"Adoption/Guardian/Custody (Legal documents required.)",
"Other (e.g. student)",
"New or Returning to Alberta"
]
},
{
"name": "dependant_date_of_event",
"type": "date",
"label": "Date of Event (yyyy-mm-dd) (Dependant)",
"options": null
},
{
"name": "dependant_arrival_place",
"type": "text",
"label": "Where did your dependant arrive from? (Country/Province/Territory)",
"options": null
},
{
"name": "dependant_arrival_date_canada",
"type": "date",
"label": "Date your dependant arrived in Canada if arrived from outside Canada (yyyy-mm-dd)",
"options": null
},
{
"name": "dependant_arrival_date_alberta",
"type": "date",
"label": "Date your dependant arrived in Alberta (yyyy-mm-dd)",
"options": null
},
{
"name": "dependant_permanent_residence_date",
"type": "date",
"label": "Date your dependant decided to live in Alberta permanently, if different from date of arrival (yyyy-mm-dd)",
"options": null
},
{
"name": "dependant_previous_health_plan_number",
"type": "text",
"label": "Previous Canadian provincial/territorial health number/medical plan number (Dependant)",
"options": null
},
{
"name": "dependant_intends_stay_12_months",
"type": "radio",
"label": "Does your dependant intend to stay in Alberta for 12 months or longer?",
"options": [
"Yes",
"No"
]
},
{
"name": "dependant_stay_explanation",
"type": "text",
"label": "Please explain why and state how long your dependant's stay will be",
"options": null
},
{
"name": "office_card_requested",
"type": "radio",
"label": "Office Use Only Card Requested",
"options": [
"Yes",
"No"
]
}
]
}