Online Forms

PHARMACY / PROVIDER DOCUMENTS
 
Pharmacy Agreements
Pharmacy Provider Agreement - English
Pharmacy Provider Enrollment Quebec Only - English
Change of Ownership Provider Agreement - English
Change of Ownership Provider Application Quebec Only - English
Entente de Fournisseur l'exception du Québec Change of Ownership Provider Agreement Not for Quebec - French
Entente de Fournisseur l'exception du Québec Provider Agreement Not for Quebec - French
Demande de Pharmacie Prestataire Québec seulement Provider Enrollment Quebec Only - French
Changement de RAMQ Provider Enrollment Change of Ownership Quebec Only - French
Pharmacy Provider Provisions
 
Pharmacy Payment Information
Quick Reference to Explanation of Payments for Pharmacies - 2012 Payment Schedule 1st & 16th of each month
AIDE-MÉMOIRE POUR OBTENIR L’EXPLICATION DU PAIEMENT DES HONORAIRES DE PHARMACIE
Payment Schedule Calendar 2011 – 12  Onward
Payment Schedule Calendar 2010
Pharmacy – Banking Payment Information Change Form – English
Pharmacie – Changement D’Information Bancaire - French
 
Pseudo-DIN List
NexgenRx PIN LIST January 2018
 
Dental Practitioners EFT Enrollment
Dental Practitioners – Direct Deposit EFT Payment Request Form
Demande de Dépôt Direct de Paiement Pour les Services Dentaires
 
Health Care Provider Documentation
Electronic Transmission Authorization and Consent Form
Plan Member News Release
Formulaire d'autorisation de transmission électronique et de consentement
Plance le portail du fournisseur de soins de santé
 
Plan Member Documents
 
DSM Diabetes
DSM Cardiovascular Wellness
DSM Musculoskeletal Disorder
 
Administration Forms
Group Coverage Enrollment Form for Health, Dental and insurance benefits
Forme Demande d'Assurance Collective pour la santé, dentaires et d'assurance
Direct Deposit Form
Formulaire de dépôt direct
Group Benefits Change Form - Fillable
Authorization_to_release_information_English
Authorization_to_release_information_French
 
Claim Forms
Drug and Extended Health Care Claim Form - English
Drug and Extended Health Care Claim Form - French
Dental Claim Form - English
Dental Claim Form - French
 
Group Benefits Request Special Evaluation Drug Exception for Members Administrators Clients Forms
Group Benefits Request Special Evaluation Drug Exception for Members and Administrators Clients
Demande d'exception pour médicament non-éligible, Bénéfices de Group _ Group Benefits Request Special Evaluation Drug Excp
 

NXG Clinical Patient Support Program Request for Exception Forms 

NXG Clinical Patient Support Program Request for Exception Form
NXG Demande D’Exemption du Programme de Soutien aux Patients en Clinique_NXG Clinical Patient Support Program Request for Exception Form
 
Prior Authorization Forms
 
English French
Actemra Actemra
Adcirca Adcirca
Aubagio Aubagio
Benlysta Benlysta
Botox Botox
Brenzys Brenzys
Cialis Levitra Staxyn Viagra Cialis Levitra Staxyn Viagra
Cialis for Benign Prostatic Hyperplasia (BPH) Cialis for Benign Prostatic Hyperplasia (BPH)
Cimzia Cimzia
Contrave Contrave
Cosentyx  Cosentyx 
Dupixent Dupixent
Dysport Dysport
Enbrel Enbrel
Entyvio Entyvio
Erelzi Erelzi
Fampyra Fampyra
Gilenya Gilenya
Humira Humira
Inflectra Inflectra
Jakavi Jakavi
Kineret Kineret
Kevzara Kevzara
Lemtrada Lemtrada
Mavenclad Mavenclad
Nucala Nucala
Olumiant Olumiant
Orencia Orencia
Otezla Otezla
Remicade Remicade
Renflexis Renflexis
Repatha Repatha
Revatio Revatio
Rituxan Rituxan
Sativex Sativex
Saxenda Saxenda
Simponi Simponi
Stelara Stelara
Taltz  
Thyrogen Thyrogen
Tremfya Tremfya
Wellbutrin [Bupropion] Wellbutrin
Xeljanz Xeljanz
Xenical Xenical
Xeomin Xeomin
Xolair Xolair