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Pharmacy Account Application

*** Note - Quebec Pharmacies are not required to complete an application – to access the providerConnect secure services, please contact us to obtain your Registration Key.

* indicates a mandatory field
Provider Information
  • Current CPHA / ODB Number:  
  • Most Current License / Pharma Care Number:  
  • Corporate Name: *
  • Trading Name: *
  • Street Address 1: *
  • Street Address 2:  
  • City: *
  • Province: *
  • Postal Code: *
Contact Information
  • Business Telephone Number: * () -
  • Fax number.   () -
  • Email Address: *
  • Confirm Email Address: *
  • Contact Name for Inquiries: *
  • Contact telephone number.   () -ext.
  • Will you be billing on behalf of your clients?

    *
Pharmacy Information
  • The effective date of pharmacy opening: * [yyyy mm dd]
  •  
  • Are you taking over for an existing pharmacy? *
  • If yes, previous corporate/trading name and Account Number:
  • Account No:  
  • Name:  
  •  
  • Are you taking over the Account Receivables? *
  • If No, you will be assigned a new Account Number.
  •  
  • Please provide the Software Vendor:  
  •  
  • Please provide the Pharmacy Network:  
  •  
  • Is this Pharmacy affiliated with another Pharmacy? *
  • If yes, indicate the Corporate Name and/or Account Number
  • Account No:  
  • Name:  
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. 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.

*** Please ensure to submit a signed copy of the Service Agreement which will be found on the next page.

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