providerConnect - Pharmacy Account Application

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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?
* 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*

*	Yes	I wish to receive an email notice as new statements are available.
	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 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. I must fill out and submit the Provider Banking Information Update form and attach a void cheque or deposit slip with the new banking information. My banking information will be updated by providerConnect within 2 business days.

Direct Deposit Agreement

*Check this box to confirm that you authorize that your payment method is Direct Deposit for the following carriers:

Green Shield Canada
SSQ Insurance

Pharmacy Information

The effective date of pharmacy opening: * [yyyy mm dd]
Are you taking over for an existing pharmacy? * Yes No
If yes, previous corporate/trading name and Account Number:
Account No:
Name:
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? * Yes No
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. You will receive an email notifying you of the status of your application within seven business days.

By completing this application, you are registering with the following carriers:

Green Shield Canada
SSQ Insurance

*** Please ensure after submitting your application to print (2) Provider Service Agreements which are found on the next page.

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