Health Professional Provider of Service Account Application

Are You Already a Member?

You are automatically part of the Provider Registry and do not need to submit an application if you meet one of these conditions:

You are submitting claims to one of the providerConnect™ Participating Carriers/Adjudicators/Third Party Payors. You will find your unique account number on your statement from the Participating Carriers/Adjudicators/Third Party Payors outlined in Schedule A within your Agreement.
If you are a member and have your registration key Activate your account here.

If you are not a member we invite you to apply today by continuing with the application process below.

*Dental providers are automatically registered, Click here.

* indicates a mandatory field

Provider Information

Name of Provider:

Clinic / Business Street Address 1:

Clinic / Business Street Address 2:

City:

Province:

Postal Code:

Is this your home address?

Yes No

Professional service type:

College / Association: College / Association:

License / Registration #:

Clinic / Business Name:

Corporate / Business Registration Number:

Clinic / Business Contact Information

Clinic / Business Telephone Number: Area Code Prefix Line number

() -

Mobile Telephone Number: Area Code Prefix Line number

() -

Fax Number: Area Code Prefix Line number

() -

Email Address:

Confirm Email Address:

Name of Clinic/Business Owner:

Will you be billing on behalf of your clients?

Will you be billing on behalf of your clients? Yes No

Payment Direction:

Payment Direction: Pay to Clinic Name Pay to Professional Name

(only the clinic will have
access to payment details)

(only the individual professional
will have access to payment details)

Do you have an existing clinic / business provider number?

Do you have an existing clinic / business provider number? Yes

Do you have an existing clinic / business provider number? No

Existing Clinic / Business Provider Number:

(Enter the provider number found on the statement of the Clinic / Business accepting payment for your services.)

Bank Account Information

The providerConnect™ site ensures that your business and financial information is handled with care. Any transactional information transmitted between you and our system is secure and cannot be read by anyone else.

Your Direct Deposit payments are issued in Canadian dollars. Any payments in U.S. currency, if authorized, will be issued by cheque.

If your Direct Deposit Banking Information changes in the future, you are responsible to update the information on the Secure Services portion of the providerConnect™ website. Failing to do so may result in a delay in payment.

Please complete the following information for your Direct Deposit preferences:

Transit
Number*

Bank
Number*

Account
Number*

I confirm that the above bank account information is for the clinic noted on this application.

Acknowledgement

Yes

I wish to receive an email notice as new statements are available.

I do not wish to receive an email notice as new statements are available. I will access my statements as needed through this website.

I authorize all Participating Carriers/Adjudicators/Third Party Payors to deposit funds directly into this bank account. I understand that I will not receive benefit statements in the mail, and my statements will only be available online via Secure Services. Once I receive my provider number, I must register for Secure Services to access my statements online.

I request that my banking information be hidden in providerConnect Secure Services. I understand that once this is hidden on providerConnect, any future changes to my banking information must be done by providerConnect.

Direct Deposit Agreement

*Check this box to confirm that you authorize that your payment method is Direct Deposit for all Participating Carriers/Adjudicators/Third Party Payors outlined in Schedule A within your Agreement.

providerConnect Secure Services Online Account Information

Create your personal User Name:

Create your password:

Confirm your password:

Note: Best practice for setting the password is to avoid using first & last name of the user.

If you forget your password, you will be asked for the answer to your challenge question. Only the correct answer to your challenge question will reset your password.

Select a challenge question:

Enter your answer to the challenge question selected:

How did you hear about us?

Once your application has been approved, your providerConnect Secure Services online account will be activated. Once processed you will receive an email notifying you of the status of your application.

By completing this application, you are registering with the Participating Carriers/Adjudicators/Third Party Payors outlined in Schedule A within your Agreement.