Non-Health or Accommodation Provider Account Application

* indicates a mandatory field
Provider Information
Facility Type: *
   
   
   
     
Please indicate the type of funding: *
   
   
     
Location Name: *
Ministry License:  
License Effective Date:   [yyyy mm dd]
Street Address 1: *
Street Address 2:  
Street Address 3:  
City: *
Province: *
Postal Code: *
Is this your Home Address: *
Contact Information
Primary Telephone Number: * () -
Fax Number:   () -
Email Address: *
Confirm Email Address: *
Contact Name for Billing Inquiries: *
Contact Telephone Number:   () -ext.
 
If Day Care:  
 
Payment Direction: *
If pay direct to Head Office, please provide mailing information
Street Address 1:  
Street Address 2:  
Street Address 3:  
City:  
Province:  
Postal Code:  
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.

Will you be billing on behalf of your clients?

*

 By completing this application, you are registering with the following carriers:
  • Green Shield Canada
  • SSQ Financial Group
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