Non-Health or Accommodation Provider Account Application

* indicates a mandatory field
Provider Information
Facility type.
*
 
 
 
 
 
 
 
 
 
Please indicate the type of funding.
*
 
 
 
 
 
 
 
*
 
License Effective Date:
 
[yyyy mm dd]
*
 
 
*
*
*
Is this your home address?
*
Contact Information
Primary telephone number.
*
() -
Fax number.
 
() -
*
The Email Address where you wish to receive email correspondence.
*
*
Contact telephone number.
 
() -ext.
 
If day care.
 
 
Payment direction.
*
If pay direct to Head Office, please provide mailing information
 
 
 
 
 
 
providerConnect Secure Services Online Account Information
* - not case sensitive
- min of 8 and max of 20 characters
- combination of alphanumeric characters (a-z|A-Z|0-9)
* - case sensitive
- minimum of 8 and maximum of 32 characters
- only alphanumeric characters (a-z,A-Z,0-9)
* - case sensitive
- minimum of 8 and maximum of 32 characters
- only alphanumeric characters (a-z,A-Z,0-9)
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 from the drop down menu that can be used to verify your identity should you forget your password or user name. Make sure to select a challenge question that is easy for you to remember.
* The answer to the Challenge Question. This is not case sensitive.
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.

Will you be billing on behalf of your clients?

*

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