Miach Orthopaedics BEAR Implant Access & Reimbursement Support Program New Office Enrollment Form Provider Enrollment - Miach Orthopaedics w/ Facilities Provider Type: * Physician’s Office Hospital/ASC Both Portal User Information User Contact Name * User Contact Name First First Last Last User Contact Email * User Contact Phone * Add Remove Practice Information Practice Name * Practice Address * Practice Address Practice Address Practice Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State ZIP Code ZIP Code Practice Phone * Practice Fax * Practice NPI * Practice Tax ID * Hospital/ASC Information Hospital/ACS Name * Hospital/ASC Address * Hospital/ASC Address Hospital/ASC Address Hospital/ASC Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State ZIP Code ZIP Code Hospital/ASC Phone * Hospital/ASC Fax * Hospital/ASC NPI * Hospital/ASC Tax ID * Add Remove Physician Information Physician Name * Physician NPI * Physician Tax ID * plus1 Add minus1 Remove Onboarding Call Availability Please select your timezone: Eastern Time Central Time Mountain Time Pacific Time Date: Onboarding Call Availability (Option 1) Date: Onboarding Call Availability (Option 2) Time EST (Option 1) 9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM1:00 PM1:30 PM2:00 PM2:30 PM3:00 PM3:30 PM4:00 PM4:30 PM Time EST (Option 2) 9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM1:00 PM1:30 PM2:00 PM2:30 PM3:00 PM3:30 PM4:00 PM4:30 PM Time CST (Option 1) 8:00 AM8:30 AM9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM1:00 PM1:30 PM2:00 PM2:30 PM3:00 PM3:30 PM Time CST (Option 2) 8:00 AM8:30 AM9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM1:00 PM1:30 PM2:00 PM2:30 PM3:00 PM3:30 PM Time MST (Option 1) 7:00 AM7:30 AM8:00 AM8:30 AM9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM1:00 PM1:30 PM2:00 PM2:30 PM Time MST (Option 2) 7:00 AM7:30 AM8:00 AM8:30 AM9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM1:00 PM1:30 PM2:00 PM2:30 PM Time PST (Option 1) 6:00 AM6:30 AM7:00 AM7:30 AM8:00 AM8:30 AM9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM1:00 PM1:30 PM Time PST (Option 2) 6:00 AM6:30 AM7:00 AM7:30 AM8:00 AM8:30 AM9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM1:00 PM1:30 PM Miach Orthopaedics Representative Name * I authorize PRIA Healthcare Management LLC, including its third-party contractors, to be my designated agent to provide any information on this form to an insurer for purposes of assisting and/or providing reimbursement or appeals support to my patients(s). * I agree Authorized Representative Signature: * signature keyboard Clear Submit If you are human, leave this field blank. PROGRAM SUPPORT: MONDAY–FRIDAY 8:30AM–5:00PM EST PHONE: 860-294-4093 FAX: 860-321-1500 EMAIL: bearimplant@priahealthcare.com
