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Health/Vision/Mental Health Provider

What do you want to do?

Provider Location

Register NEW Provider Location

Terminate (Close) Provider Location

Change of Address and/or Location Name

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

Practitioner

Add Practitioner(s)

Remove Practitioner(s)

Add Paramedical Service(s)

Practitioner Name Change

General Inquiry

Contact Us

New Health Vision

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

*Firstname

*Lastname

*Email

STANDARD Administrator Access Request

Role of PROVIDERnet Standard Administrator:

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

*Firstname

*Lastname

*Email

REMOVE Administrator Access

*Firstname

*Lastname

*Email

*Effective Date

*PBC Provider ID

This is your PBC-assigned ID

Business Information

*Business Legal Name

*Business Operating Name

*Phone

Fax

*Business Email

*Street Address

*City

*Province

*Postal Code

Note: This form is for use only by Health/Vision Providers in British Columbia, as well as Vision Providers in Alberta and Mental Health Providers outside of BC serving FNHA clients.

Updated Business Information

*Business Legal Name

*Business Operating Name

*Phone

Fax

*Business Email

*Street Address

*City

*Province

*Postal Code

Add/Remove Practitioners

Please attach a document that displays your college registration number. Failure to do so will delay registration.

*First Day/Last Day at Location

*Firstname

*Lastname

*Practitioner Email

Personal email address of the practitioner only. CANNOT be the same as the PRIMARY ADMINISTRATOR email address for the clinic

RegistrationNumber

*Regulatory/Licensing Body

*Document displaying college registration number

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

*Registration Effective Date

Update Practitioner Name

Existing Name

*Firstname

*Lastname

Change To:

*NEW Firstname

*NEW Lastname

Regulatory Info

RegistrationNumber

*Regulatory/Licensing Body

Additional Comments

Additional Comments

Signature

By checking this box, I confirm that the information in this application is true and accurate. I agree to notify Pacific Blue Cross (PBC) of any change in business manager, owner or legal name in the event of a change in ownership or director of business. Violations of any Pacific Blue Cross Policy, non-compliance of any Healthcare Provider Agreement or Vision Provider Agreement will result in the cancellation of the provider number

*Applicant Full Name

Person filling in this application

*Applicant Occupation Title

*Applicant Email

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