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Hearing Provider

What do you want to do?

Register new Provider Location

Terminate (Close) Business

Change of Ownership

Change of Address

Change of Operating Name

Contact Us

ADD/REMOVE Administrator Access
(direct deposit, online claiming, statements, etc.)

Where is the business located?

New Hearing

Email Address Guidelines

Since a Primary Administrator has full access to view and change banking information, we discourage using a multi-user or communal email address, e.g. admin@ProviderClinic.ca.
Pacific Blue Cross Assumes or takes no responsibility for any consequences, directly or indirectly, that may arise from registering with a clinic/communal email address
Emails must be unique in PROVIDERnet

PRIMARY Administator Access Request (Business Owner)

Role of PROVIDERnet Primary Administrator:

The Primary Administrator is usually the business owner or director
Self-serve access to set-up, change, view banking information for direct deposit for the business owner
Can view pre-authorizations, submit eligible claims, electronic statements

*First Name

*Last Name

*Email

STANDARD Administrator Access Request

Role of PROVIDERnet Standard Administrator:

Can view pre-authorizations, submit eligible claims, view claims history

*First Name

*Last Name

*Email

REMOVE Administrator Access

*First Name

*Last Name

*Email

*Effective Date

*PBC Provider ID

This is your PBC-assigned ID

License Information

UploadedFile

Upload a copy (.pdf, .png, .gif, .jpg) of your business operating license. Max 1.5MB.

Business Information

*Store Manager

*Name of Owner or Director

*Owner Email

Used for PROVIDERnet Access as Primary Administrator

*Business/Payee Name

Name of the Business that will be paid and must match your bank account information.

*Operating Name

*Phone

Fax

*Email

*Street Address

*City

*Province

*Postal Code

Is your mailing address different from above?

*Street Address

*City

*Province

*Postal Code

Updated Business Information

*Business/Payee Name

Name of the Business that will be paid and must match your bank account information.

*Operating Name

*Phone

Fax

*Email

*Street Address

*City

*Province

*Postal Code

Is your mailing address different from above?

*Street Address

*City

*Province

*Postal Code

Practitioner Information

Attach a copy of your practitioners certificate. Failure to do so will delay registration.

*Firstname

*Lastname

*Regulatory/Licensing Authority

*Copy of certification

Upload a copy (.pdf, .png, .gif, .jpg) of your Certification. Max 2MB.

Additional Comments

Additional Comments

Signature

By checking this box, I confirm the information on this application is true and accurate. I agree to notify Pacific Blue Cross of any change in owner or Director of Business, as well as any change in legal name in the event of a change in ownership. Violation or non-compliance of any Pacific Blue Cross (PBC) policy, ProviderNet Terms and Conditions and the Hearing Provider Reference Guide , will result in the cancellation of the provider number.

*Full Name

Person filling in this application

*Occupation Title

*Email

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