What do you want to do?

Close Pharmacy

Change of Ownership

Change of Address

Change of Operating Name

ADD Administrator Access
(direct deposit, statements, etc.)

Where is the pharmacy located?

New Pharmacy

*Effective Date

*PBC Provider ID

This is your PBC-assigned 10 digit ID number, i.e.: BC00000A##

License Information

HIBC Letter

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

*Pharmacy Operating License / Accreditation / Permit number (as assigned by provincial regulatory body)

Pharmacy Information

Type of Business

Independent

Banner

Chain

*Managing Pharmacist

*Name of Owner or Director

*Owner Email

Used only for sending pharmacy agreement for signature

*Pharmacy Legal Name

*Pharmacy Operating Name

*Phone

Fax

*Business Email

*Street Address

*City

*Province

*Postal Code

Is your mailing address different from above?

*Street Address

*City

*Province

*Postal Code

Updated Pharmacy Information

*Pharmacy Legal Name

*Pharmacy Operating Name

*Phone

Fax

*Business Email

*Street Address

*City

*Province

*Postal Code

Is your mailing address different from above?

*Street Address

*City

*Province

*Postal Code

Pay-Direct Transmission Information (BC and YT only)

This information is required to enable Pay-Direct claim transmission. Ask your software vendor if you are unsure of your IP address.

TCP/IP Address

If more than one computer terminal, enter your usable LAN IP range

Please note that IP addresses that fall within the following ranges are reserved for internal networks only and will not transmit to PBC:

10.0.0.0 - 10.255.255.255
172.16.0.0 - 172.31.255.255
192.168.0.0 - 192.168.255.255

For WinRx: Please provide IP address connected to the Pharmanet system router.
For Kroll: Please provide IP address defined as External IP under Kroll Connect.

Please ensure that your software vendor has correctly configured your connection.

Pharmacy PROVIDERnet Web Access Request

Role of PROVIDERnet Primary Administrator

The Primary Administrator is usually the pharmacy owner or director of business
Self-serve access to set up, change, view banking information for direct deposit.
Can view electronic statements
Create new "Standard" or other "Primary" administrators if you choose to delegate to an office manager. A "Standard Administrator" has "view only" access for electronic statements and no access to banking information.

Email Address Guidelines

Since a Primary Administrator has full access to view and change banking information as well as create other Primary Administrators, we discourage using a multi-user or communal pharmacy email address, e.g. admin@pharmacyname.com. 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 Administrator Email

This will be the login for PROVIDERnet

*Primary Administrator Firstname

*Primary Administrator Lastname

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 pharmacy manager, owner or legal name in the event of a change in ownership or Director of Business. Violation of any Pacific Blue Cross policy, noncompliance of any Pharmacy Agreement, or PBC Pharmacy Reference Guide, will result in the cancellation of the provider number.

*Applicant Full Name

Person filling in this application

*Applicant Occupation Title

*Applicant Email

Pharmacy Account Management

New Pharmacy

Role of PROVIDERnet Primary Administrator

Email Address Guidelines