Request to add a practitioner to an existing account for online direct billing

Please submit the following practitioner information to us. Once the practitioner has been linked with your clinic, you’ll receive a confirmation email and you can then add them as a practitioner during time of claim entry. If you have any additional questions, please contact us directly at 1-800-588-1195.

Please enter name of the provider
Please select a provider type

Is this a new service type being added to your clinic? *

Please enter the name of college or association
Please enter the college or association number
Please enter the practice name.
Please enter the practice address.
Please enter your city/town.
Please select your province.
Please enter your postal code.
Please enter a valid phone number.
Please enter the practice login ID
Please enter an email address.