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

Provincial License Number/ODB ON Number/BC PharmaCare Number:

Corporate Name: *

Trading Name: *

Street Address 1: *

Street Address 2:

City: *

Province: *

Postal Code: *

Contact Information

Business Telephone Number: Business Telephone Number: * Area Code Prefix Line number

() -

Fax number. Fax number. Area Code Prefix Line number

() -

Pharmacy Email Address: *

Confirm Pharmacy Email Address: *

Contact Name for Inquiries: *

Contact telephone number prior to opening: Contact telephone number prior to opening: Area Code Prefix Line number ext.

() -ext.

Will you be billing on behalf of your clients?

Will you be billing on behalf of your clients? Yes No

Bank Account Information

The providerConnect™ site ensures that your business and financial information is handled with care. Any transactional information transmitted between you and our system is secure and cannot be read by anyone else.

Your Direct Deposit payments are issued in Canadian dollars. Any payments in U.S. currency, if authorized, will be issued by cheque.

If your Direct Deposit Banking Information changes in the future, you are responsible to update the information on the Secure Services portion of the providerConnect™ website. Failing to do so may result in a delay in payment.

Please complete the following information for your Direct Deposit preferences:

Transit
Number*

Bank
Number*

Account
Number*

I wish to receive an email notice as new statements are available. Yes

I wish to receive an email notice as new statements are available.

I do not wish to receive an email notice as new statements are available. I will access my statements as needed through this website. No

I do not wish to receive an email notice as new statements are available. I will access my statements as needed through this website.

I authorize all Participating Carriers/Adjudicators/Third Party Payors to deposit funds directly into this bank account. I understand that I will not receive benefit statements in the mail, and my statements will only be available online via Secure Services. Once I receive my provider number, I must register for Secure Services to access my statements online.

I request that my banking information be hidden in providerConnect Secure Services. I understand that once this is hidden on providerConnect, any future changes to my banking information must be done by providerConnect.

Direct Deposit Agreement

*Check this box to confirm that you authorize that your payment method is Direct Deposit for all Participating Carriers/Adjudicators/Third Party Payors outlined in Schedule A within your Agreement.

Pharmacy Information

The effective date of pharmacy opening: * years Month Day [yyyy mm dd]

Contact email prior to opening:

Are you taking over for an existing pharmacy? *

Are you taking over for an existing pharmacy? Yes No

If yes, previous corporate/trading name and Provider Number:

Provider Number:

Name:

Are you taking over the Account Receivables? *

Are you taking over the Account Receivables? Yes No

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? *

Is this Pharmacy affiliated with another Pharmacy? Yes No

If yes, indicate the Corporate Name and/or Account Number

Provider Number:

Name:

providerConnect Secure Services Online Account Information

Create your personal User Name:

Create your password:

Confirm your password:

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:

Enter your answer to the challenge question selected:

How did you hear about us?

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.