Dental Provider Enrolment Form

ADVERTISEMENT

DENTAL PROVIDER ENROLMENT FORM
NON-INSURED HEALTH BENEFITS (NIHB) PROGRAM
Complete, sign and return ALL pages of the Enrolment Form by fax or mail to:
Fax No.: 1-855-622-0669
th
Mail: Express Scripts Canada, Attention: Provider Relations, 5770 Hurontario St., 10
Floor, Mississauga, ON L5R 3G5
DENTAL PROVIDER INFORMATION
Language:  English
 French
Unique Provider No.:
Surname:
First Name:
License No.:
Specialty:
General Communication (select one):  E-mail
 Fax  Mail
Select your delivery mode preference for each type of
communication:
Predetermination Letters (select one):  Fax
 Mail
Please indicate your status in the clinic (select one):
 Associate (not an owner and/or owner partner)
 Owner and/or Owner Partner
 Salary or  Per Diem Dental Professional Contracted by Health Canada Regional Offices
CLINIC/OFFICE INFORMATION
If more space is required to include additional offices, please provide the information required below on an additional page and attach to the completed
Enrolment form.
MAIN OFFICE
ADDITIONAL OFFICE
Effective Date: _________________________________________
Effective Date: _________________________________________
Status (select one):  Owner
 Associate
Status (select one):  Owner
 Associate
 Salary or
 Salary or
 Per Diem Dental Professional Contracted
 Per Diem Dental Professional Contracted
by Health Canada Regional Offices
by Health Canada Regional Offices
Office ID (CDAnet/ DACnet
/ ACDQ): _______________________
Office ID (CDAnet/ DACnet
/ ACDQ): _______________________
Clinic Name:____________________________________________
Clinic Name: ___________________________________________
Street Address: _________________________________________
Street Address: _________________________________________
Suite/ P.O. Box: _________________________________________
Suite/ P.O. Box: _________________________________________
City: __________________________________________________
City: __________________________________________________
Prov.: _____________ Postal Code: ________________________
Prov.: _____________ Postal Code: ________________________
Phone No.: _________________ Fax No.: ____________________
Phone No.: _________________ Fax No.: ____________________
E-mail Address: _________________________________________
E-mail Address: _________________________________________
PAYMENT INFORMATION – ELECTRONIC FUNDS TRANSFER (EFT)
I instruct Express Scripts Canada to set up direct EFT PAYMENTS. This form authorizes deposits to the account and does not
authorize withdrawals or any other transactions with respect to the account. All information will be treated as private and confidential.
I will advise Express Scripts Canada promptly of any changes to bank, branch or account number.
Office ID (CDAnet/ DACnet
/ ACDQ): ___________________________
Complete bank information below and  Attach a VOID Cheque or Official Bank Letter
(Photocopy of VOID cheque is acceptable when faxing)
Bank Name: ________________________________________ Branch Name: ____________________________________________
Branch Address: _______________________________________________________________________________________________
City: ______________________________________________ Province: ________________
Postal Code: ___________________
Bank No.: |
|
|
| Branch/ Transit No.: |
|
|
|
|
| Account No.: |
|
|
|
|
|
|
|
|
|
|
|
Express Scripts Canada/ March 2013-Version 3.0
DENTAL PROVIDER ENROLMENT FORM NIHB PROGRAM
Page 1 of 2

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 2