Get Pharmacy Stakeholder Registration Form - Cbproviders

Completing the Pharmacy Stakeholder Registration Form online is an essential step for pharmacies looking to engage with the CBP program. This guide provides clear, step-by-step instructions to help users fill out the form accurately and efficiently.

Follow the steps to complete your registration form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide the pharmacy information. Fill in the 'Corporate Name' field accurately. Indicate whether this pharmacy is part of a chain by selecting 'Yes' or 'No'. If applicable, include the corporate name or chain store number.
3. Complete the effective date of opening. If taking over an existing pharmacy, provide the previous corporate name or provider ID.
4. Fill out the software vendor and version number. Additionally, enter the pharmacy license number and the usual and customary dispensing fee(s).
5. Move on to the business address section. Input the complete address, including 'Address 1', 'Address 2', city, province, postal code, telephone, and FAX number.
6. Next, fill in the contact information. Enter the contact name, telephone number, and email address for further communication.
7. Now, provide the banking information. Enter the name on the account, bank name, and bank address. Include the bank number, transit number, and account number.
8. Specify the effective date for payments in the mm/dd/yyyy format and indicate whether a void cheque is attached.
9. Review the registration agreement about claims submissions and ensure understanding of payment schedules.
10. Finally, sign the form and enter the date, signatory name, and title. Once completed, you can save your changes, download, print, or share the form as needed.

Complete your Pharmacy Stakeholder Registration Form online today to ensure your pharmacy is registered with CBP.