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PHARMACY / PROVIDER DOCUMENTS |
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Pharmacy Agreements (including EFT enrolment) |
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Pharmacy Agreement |
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Accord de pharmacie (l'exception au Québec) |
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Pharmacy / Provider Enrollment (Quebec Only) |
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Demande de Pharmacie Prestataire (Québec Seulement) |
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Provider EFT Enrolment |
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Dental – Direct Deposit Payment Request Form |
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Demande de Dépôt Direct de Paiement Pour les Services Dentaires |
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Payment Information |
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Explanation of Payments – Quick Reference for Pharmacies |
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Explanation of Payments - Calendar Schedule 2010 |
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Explanation of Payments - Calendar Schedule 2011 |
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Pharmacy – Banking Payment Information Change Form (Providers) – English |
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Pharmacy – Banking Payment Information Change Form (Providers) - French |
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PLAN MEMBER DOCUMENTS |
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Administration Forms |
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Enrolment Form for Health and Dental benefits only |
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Group Coverage Enrolment Form for Health, Dental and insurance benefits |
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Forme Demande d'Assurance Collective pour la santé, dentaires et d'assurance |
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Direct Deposit Form |
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Claim Forms |
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Drug and Extended Health Care Claim Form- English |
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Drug and Extended Health Care Claim Form - French |
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Dental Claim Form - English |
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Dental Claim Form - French |
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Prior Authorization Forms |
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Amevive |
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Anti Depressant |
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Anti Obesity |
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Biologics for RA and Crohns |
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Botulinum Toxin Anti-neuromuscular |
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Erectile Dysfunction |
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Gilenya |
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Thyroid Cancer Diagnostic Testing |
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Xolair |
