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