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Compliance Packaging Form - providerConnect

Compliance Packaging Form - providerConnect 2026

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The document is a request form for coverage of additional dispensing fees related to compliance packaging for medications. It includes sections for the plan member to declare their need for compliance packaging, a pharmacist's declaration supporting the request, and instructions for submitting the form to Green Shield Canada. The form emphasizes the potential added costs and implications on benefit plan maximums.

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Click ‘Get Form’ to open the Compliance Packaging Form - providerConnect in the editor.
Begin with Section 1: Plan Member Declaration. Enter the Plan Member Name and GSC ID #. Specify the dispensing frequency in days and acknowledge that compliance packaging is not child-safe by signing at the bottom.
Proceed to Section 2: Pharmacist Declaration. The pharmacist should indicate their professional judgment regarding the need for compliance packaging, selecting applicable reasons and providing supporting information in the designated space.
Complete Section 3: Form Submission Instructions by ensuring all sections are filled out completely. Follow the instructions to fax the form to Green Shield Canada’s Drug Special Authorization Department.

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