Health Professional Provider of Service Account Application

*Dental providers are automatically registered, Click here.

* indicates a mandatory field
Provider Information
Name: *
Street Address 1: *
Street Address 2:  
City: *
Province: *
Postal Code: *
Is this your Home Address: *
Professional Service Type: *
College / Association:

or
License / Registration #:
Attach Provider Diploma/Certificate/Other Credentials (Overall maximum per submission is 4 MB):
1.    
2.    
3.    
Clinic / Business Name: *
Corporate / Business Registration Number:
Contact Information
Business Telephone Number: * () -
Contact Telephone Number:   () -
Fax Number:   () -
Email Address: *
Confirm Email Address: *
 
Will you be billing on behalf of your clients? *
 
Payment Direction: *
(only the clinic will have
access to payment details)
    
(only the individual professional
will have access to payment details)
    
providerConnect Secure Services Online Account Information
Create your personal User Name: *
Create your password: *
Confirm your password: *
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: *
Once your application has been approved, your providerConnect Secure Services online account will be activated. You will receive an email notifying you of the status of your application within seven business days.
By completing this application, you are registering with the following carriers:
  • Green Shield Canada
  • SSQ Financial Group
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