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
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:
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providerConnect Secure Services Online Account Information
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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.
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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.