Form Schema - gpt-4.1-mini-2025-04-14
{
"title": "Alberta Health Care Insurance Plan Notice of Change/Addition",
"fields": [
{
"name": "lastName",
"type": "text",
"label": "Last Name"
},
{
"name": "firstName",
"type": "text",
"label": "First Name"
},
{
"name": "middleName",
"type": "text",
"label": "Middle Name"
},
{
"name": "personalHealthNumber",
"type": "text",
"label": "Personal Health Number"
},
{
"name": "newLastName",
"type": "text",
"label": "New Last Name (If applicable. Proof required. See page .)"
},
{
"name": "dateOfBirth",
"type": "date",
"label": "Date of Birth (yyyy-mm-dd)"
},
{
"name": "genderMale",
"type": "checkbox",
"label": "Male"
},
{
"name": "genderFemale",
"type": "checkbox",
"label": "Female"
},
{
"name": "phoneNumber",
"type": "text",
"label": "Phone Number"
},
{
"name": "mailingAptUnit",
"type": "text",
"label": "Mailing Address Apt./Unit #"
},
{
"name": "mailingStreet",
"type": "text",
"label": "Mailing Address Street"
},
{
"name": "newAddress",
"type": "checkbox",
"label": "Check if this is a new address"
},
{
"name": "mailingCityTown",
"type": "text",
"label": "Mailing Address City/Town"
},
{
"name": "mailingProvince",
"type": "text",
"label": "Mailing Address Province"
},
{
"name": "mailingPostalCode",
"type": "text",
"label": "Mailing Address Postal Code"
},
{
"name": "homeAptUnit",
"type": "text",
"label": "Home Address Apt./Unit #"
},
{
"name": "homeStreetLegal",
"type": "text",
"label": "Home Address Street or legal land description (if different from mailing address)"
},
{
"name": "homeCityTown",
"type": "text",
"label": "Home Address City/Town"
},
{
"name": "homeProvince",
"type": "text",
"label": "Home Address Province"
},
{
"name": "homePostalCode",
"type": "text",
"label": "Home Address Postal Code"
},
{
"name": "spouseLastName",
"type": "text",
"label": "Adding Coverage for a Spouse/Adult Interdependent Partner Last Name (Proof of identity required. See page.)"
},
{
"name": "spousePreviousLastName",
"type": "text",
"label": "Previous Last Name(s) (if applicable)"
},
{
"name": "spousePersonalHealthNumber",
"type": "text",
"label": "Personal Health Number (if known)"
},
{
"name": "spouseFirstName",
"type": "text",
"label": "First Name"
},
{
"name": "spouseMiddleName",
"type": "text",
"label": "Middle Name"
},
{
"name": "spouseDateOfBirth",
"type": "date",
"label": "Date of Birth (yyyy-mm-dd)"
},
{
"name": "spouseGenderMale",
"type": "checkbox",
"label": "Male (Spouse)"
},
{
"name": "spouseGenderFemale",
"type": "checkbox",
"label": "Female (Spouse)"
},
{
"name": "spouseCitizenYesNo",
"type": "radio",
"label": "Is your spouse/adult interdependent partner a Canadian citizen?"
},
{
"name": "spousePermanentResident",
"type": "checkbox",
"label": "Permanent Resident"
},
{
"name": "spouseStudyPermit",
"type": "checkbox",
"label": "Study Permit"
},
{
"name": "spouseWorkPermit",
"type": "checkbox",
"label": "Work Permit"
},
{
"name": "spouseVisitorRecord",
"type": "checkbox",
"label": "Visitor Record"
},
{
"name": "spouseOther",
"type": "text",
"label": "Other"
},
{
"name": "spouseIssueDate",
"type": "date",
"label": "Issue Date (yyyy-mm-dd)"
},
{
"name": "spouseExpiryDate",
"type": "date",
"label": "Expiry Date (yyyy-mm-dd)"
},
{
"name": "spouseHadCoverage",
"type": "radio",
"label": "Does your spouse/adult interdependent partner currently have, or have they previously had, AHCIP coverage?"
},
{
"name": "spousePreviousHealthNumber",
"type": "text",
"label": "Previous Alberta Personal Health Number (if known)"
},
{
"name": "spouseReasonMarriage",
"type": "checkbox",
"label": "Why are you adding your spouse/adult interdependent partner to your account? (Check all that apply) Marriage or Adult Interdependent Partnership"
},
{
"name": "spouseDateOfEvent",
"type": "date",
"label": "Date of Event (yyyy-mm-dd)"
},
{
"name": "spouseReasonNewReturning",
"type": "checkbox",
"label": "New or Returning to Alberta"
},
{
"name": "spouseReleasedMilitary",
"type": "checkbox",
"label": "Released from Military"
},
{
"name": "spouseReleasedFederal",
"type": "checkbox",
"label": "Released from Federal Institution"
},
{
"name": "spouseDateReleased",
"type": "date",
"label": "Date Released (yyyy-mm-dd)"
},
{
"name": "spouseArrivedFrom",
"type": "text",
"label": "Where did your spouse/adult interdependent partner arrive from? (Country/Province/Territory)"
},
{
"name": "spouseArrivedCanadaDate",
"type": "date",
"label": "Date spouse arrived in Canada if arrived from outside Canada (yyyy-mm-dd)"
},
{
"name": "spouseArrivedAlbertaDate",
"type": "date",
"label": "Date spouse arrived in Alberta (yyyy-mm-dd)"
},
{
"name": "spousePermanentDate",
"type": "date",
"label": "Date spouse decided to live in Alberta permanently if different from date of arrival (yyyy-mm-dd)"
},
{
"name": "spousePreviousCanadianHealthNumber",
"type": "text",
"label": "Previous Canadian provincial/territorial health number/medical plan number"
},
{
"name": "spouseIntendStayLonger",
"type": "radio",
"label": "Does your spouse/adult interdependent partner intend to stay in Alberta for 12 months or longer?"
},
{
"name": "spouseIntendStayExplain",
"type": "text",
"label": "Please explain why and state how long they stay will be"
},
{
"name": "registrantSignature",
"type": "text",
"label": "Registrant Signature"
},
{
"name": "spouseSignature",
"type": "text",
"label": "Spouse/Adult Interdependent Partner Signature"
},
{
"name": "dependantLastName",
"type": "text",
"label": "Dependant Last Name"
},
{
"name": "dependantFirstName",
"type": "text",
"label": "Dependant First Name"
},
{
"name": "dependantMiddleName",
"type": "text",
"label": "Dependant Middle Name"
},
{
"name": "dependantPersonalHealthNumber",
"type": "text",
"label": "Personal Health Number (if known)"
},
{
"name": "dependantDateOfBirth",
"type": "date",
"label": "Date of Birth (yyyy-mm-dd)"
},
{
"name": "dependantGenderMale",
"type": "checkbox",
"label": "Male (Dependant)"
},
{
"name": "dependantGenderFemale",
"type": "checkbox",
"label": "Female (Dependant)"
},
{
"name": "dependantDateOfDependency",
"type": "date",
"label": "Date of Dependency (yyyy-mm-dd)"
},
{
"name": "dependantRelationship",
"type": "text",
"label": "Relationship to dependant (e.g. parent, guardian)"
},
{
"name": "dependantCitizenYesNo",
"type": "radio",
"label": "Is your dependant a Canadian citizen?"
},
{
"name": "dependantPermanentResident",
"type": "checkbox",
"label": "Permanent Resident (Dependant)"
},
{
"name": "dependantStudyPermit",
"type": "checkbox",
"label": "Study Permit (Dependant)"
},
{
"name": "dependantWorkPermit",
"type": "checkbox",
"label": "Work Permit (Dependant)"
},
{
"name": "dependantVisitorRecord",
"type": "checkbox",
"label": "Visitor Record (Dependant)"
},
{
"name": "dependantOther",
"type": "text",
"label": "Other (Dependant)"
},
{
"name": "dependantIssueDate",
"type": "date",
"label": "Issue Date (yyyy-mm-dd) (Dependant)"
},
{
"name": "dependantExpiryDate",
"type": "date",
"label": "Expiry Date (yyyy-mm-dd) (Dependant)"
},
{
"name": "dependantHadCoverage",
"type": "radio",
"label": "Does your dependant currently have, or have they previously had, AHCIP coverage?"
},
{
"name": "dependantPreviousHealthNumber",
"type": "text",
"label": "Previous Alberta Personal Health Number (if known) (Dependant)"
},
{
"name": "dependantPreviousName",
"type": "text",
"label": "Name your dependant was previously registered under (if known)"
},
{
"name": "dependantReasonBirth",
"type": "checkbox",
"label": "Why are you adding this dependant to your AHCIP coverage? Birth"
},
{
"name": "dependantReasonBirthAlberta",
"type": "checkbox",
"label": "Birth in Alberta"
},
{
"name": "dependantReasonAdoptionGuardian",
"type": "checkbox",
"label": "Adoption/Guardian/Custody (Legal documents required.)"
},
{
"name": "dependantReasonOther",
"type": "text",
"label": "Other (e.g. student)"
},
{
"name": "dependantDateOfEvent",
"type": "date",
"label": "Date of Event (yyyy-mm-dd) (Dependant)"
},
{
"name": "dependantArrivedFrom",
"type": "text",
"label": "Where did your dependant arrive from? (Country/Province/Territory)"
},
{
"name": "dependantArrivedCanadaDate",
"type": "date",
"label": "Date your dependant arrived in Canada if arrived from outside Canada (yyyy-mm-dd)"
},
{
"name": "dependantArrivedAlbertaDate",
"type": "date",
"label": "Date your dependant arrived in Alberta (yyyy-mm-dd)"
},
{
"name": "dependantPermanentDate",
"type": "date",
"label": "Date your dependant decided to live in Alberta permanently if different from date of arrival (yyyy-mm-dd)"
},
{
"name": "dependantPreviousCanadianHealthNumber",
"type": "text",
"label": "Previous Canadian provincial/territorial health number/medical plan number (Dependant)"
},
{
"name": "dependantIntendStayLonger",
"type": "radio",
"label": "Does your dependant intend to stay in Alberta for 12 months or longer?"
},
{
"name": "dependantIntendStayExplain",
"type": "text",
"label": "Please explain why and state how long your dependant's stay will be"
},
{
"name": "cardRequestedYes",
"type": "checkbox",
"label": "Card Requested (Yes)"
},
{
"name": "cardRequestedNo",
"type": "checkbox",
"label": "Card Requested (No)"
}
]
}