Pharmacy 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.
  • You are a Quebec Pharmacist registered with AQPP. We automatically register Quebec Pharmacy providers based on membership lists we receive from AQPP. Please Contact Us to receive your registration key in order to activate your providerConnect Secure Services online account.
  • 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.

*** 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

 
*
*
*
 
*
*
*

Contact Information

Business Telephone Number: * () -
Fax number.   () -
* The Pharmacy Email Address where you wish to receive email correspondence.
*
*
Contact telephone number.   () -ext.

*
Will you be billing on behalf of your clients?

Pharmacy Information

* [yyyy mm dd]
 
*
Are you taking over for an existing pharmacy?
If yes, previous corporate/trading name and Provider Number:
 
 
 
*
Are you taking over the Account Receivables?
If No, you will be assigned a new Account Number.
 
 
 
 
 
*
Is this Pharmacy affiliated with another Pharmacy?
If yes, indicate the Corporate Name and/or Account Number
 
 
providerConnect Secure Services Online Account 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)
* - Password minimum length should be between 8 to 32 characters
- A minimum of one upper-case letter
- A minimum of one lower-case letter
- A minimum of one number
- A minimum of one special character ( Allowed characters ~!@$%^&*_-+=`|\(){}[]:;,.?/)    
- Must not contain any blanks or spaces
* - Password minimum length should be between 8 to 32 characters
- A minimum of one upper-case letter
- A minimum of one lower-case letter
- A minimum of one number
- A minimum of one special character ( Allowed characters ~!@$%^&*_-+=`|\(){}[]:;,.?/)    
- Must not contain any blanks or spaces

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 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 must be a minimum of 5 characters and 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.
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.