Health Professional Provider of Service 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.
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.

*Dental providers are automatically registered, Click here.

* indicates a mandatory field

Provider Information

First and Last Name of Provider (enter name as it appears on your receipts / invoices):

Clinic / Business Street Address 1:

Clinic / Business Street Address 2:

City:

Province:

Postal Code:

Is this your home address?

Yes No

Professional service type:

College / Association: College / Association:

License / Registration #:

Clinic / Business Name:

Corporate / Business Registration Number:

Clinic / Business Contact Information

Clinic / Business Telephone Number: Area Code Prefix Line number

() -

Mobile Telephone Number: Area Code Prefix Line number

() -

Email Address:

Confirm Email Address:

Name of Clinic/Business Owner:

Do you have an existing clinic / business provider number?

Bank Yes

Bank No

Existing Clinic / Business Provider Number:

(Enter the provider number found on the statement of the Clinic / Business accepting payment for your services.)

Important Payment Information - When your application is processed, you will receive an email advising you are ready to login to your providerConnect account, upon logging in you will be prompted to add the banking information that you wish to use in order to receive payment if you are billing on behalf of your clients. Payment will only be issued by direct deposit.

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.