Sample Modifications to Pharmacy/Medical Supplies and Equipment (MS&E) Information Form

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Sample Modifications to Pharmacy/Medical Supplies and Equipment Information Form

First Canadian Health (FCH) requires certain information about each participating Pharmacy/MS&E Provider to properly identify and pay the Pharmacy/MS&E Provider for claims adjudicated by FCH. Please complete this form and return it with the signed Pharmacy/MS&E Provider Agreement. Cheque payment will be mailed to the Operating Store address unless Section 2 or 3 of the form are completed.

Section 1 - Pharmacy/Medical Supplies and Equipment Provider Information:

First Canadian Health (FCH) Pharmacy / Medical Supplies and Equipment Provider Number

Operating (Store) Name
Street Address
City
Province
Postal Code
Language Preferred: English/French
Telephone Number
Fax Number
Contact Name
Title

Section 2 - Pharmacy/Medical Supplies and Equipment Provider Mailing Address

Note: This section is completed only if cheque payment should NOT be mailed to the Operating Store address indicated in Section 1 of the form.

Operating (Store) Name
Street Address
City
Province
Postal Code
Language Preferred: English/French
Telephone Number
Fax Number
Contact Name
Title

Section 3 - Electronic Funds Transfer (EFT) Payment Information:

This section is completed to identify the account to which FCH will direct EFT PAYMENTS and attach a sample/VOID cheque. (This form authorizes deposits to the account and does not authorize withdrawals or any other transactions with respect to the account. All information will be treated as private and confidential).

New Banking Information/Replace Banking Information
Bank Name
Branch Name
Branch Address
City
Province
Post Code

Account Number Information:
Bank
Branch
Account Number

Section 4 - Pharmacy/Medical Supplies and Equipment Provider Management System and Point of Sale (POS) Claims Submission:

FCH offers a real-time adjudication system, which is compatible with Pharmacy Practice Management Systems (PPMS) and specially equipped Point of Sale (POS) Devices. In order to submit claims real-time (POS), you must contact your Pharmacy/MS&E Provider software vendor. Please provide the following information if you are currently using a PPMS or POS device:

• Vendor (Company) Name;
• Area Code;
• Telephone Number;
• Contact Address;
• City;
• Province; and
• Postal Code.