Provider Enrollment - ReApplix

3C Patch Reimbursement Support Program

Please click here to complete a BAA with your enrollment

New Office Enrollment Form

Portal User Information

User Contact Name

First

Last

User Contact Email *

User Contact Phone *

Add Remove

Practice Name *

Practice Phone Number *

Practice Fax Number *

Practice Address

Practice Address *

Practice Address

City

State/Province

Zip/Postal

Practice NPI *

Practice Tax ID *

Add Remove

Physician Information

Physician Name

First

Last

Individual Physician PTAN (Medicare Provider Identification Number) *

Physician Tax ID *

Physician NPI *

Add Remove

Facility Information

Facility Name *

Facility Address *

Facility Address

City

State/Province

Zip/Postal

Facility Phone *

Facility Tax ID *

Facility NPI *

Add Remove

ReApplix Sales Representative Name *

Date: Onboarding Call Availability (Option 1)

Date: Onboarding Call Availability (Option 2)

Time EST (Option 1)

Time EST (Option 2)

PROGRAM SUPPORT:

MONDAY–FRIDAY 8:30AM–5:00PM EST
PHONE: 866-3CP-3025 FAX: 860-516-1546
EMAIL: 3CPatch@priahealthcare.com

Provider Enrollment – ReApplix

3C Patch Reimbursement Support Program

Please click here to complete a BAA with your enrollment

New Office Enrollment Form

Portal User Information

Practice Address

Physician Information

Facility Information