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
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Contact Information
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  • * The Email Address where you wish to receive email correspondence.
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    Will you be billing on behalf of your clients?
Pharmacy Information
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    Are you taking over for an existing pharmacy?
  • If yes, previous corporate/trading name and Account Number:
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    Are you taking over the Account Receivables?
  • If No, you will be assigned a new Account Number.
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    Is this Pharmacy affiliated with another Pharmacy?
  • If yes, indicate the Corporate Name and/or Account Number
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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)
* - case sensitive
- minimum of 8 and maximum of 32 characters
- only alphanumeric characters (a-z,A-Z,0-9)
* - case sensitive
- minimum of 8 and maximum of 32 characters
- only alphanumeric characters (a-z,A-Z,0-9)
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.