SAINT Reimbursement Support Line New Office Enrollment Form Click here to complete a Business Associate Agreement (BAA) with your enrollment Provider Enrollment - Magnus Medical Contact Information Office Contact Name * Office Contact Name First First Last Last Office Contact Email * Office Contact Phone * Billing Contact Name Billing Contact Name First First Last Last Billing Contact Email Billing Contact Phone Add Remove Practice/Group Information Practice/Group Name * Practice/Group Address * Practice/Group Address Practice/Group Address Practice/Group Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State ZIP Code ZIP Code Practice/Group Phone * Practice/Group Fax * Practice/Group NPI * Practice/Group ID * Physician Information Physician Name * Physician Specialty * Physician NPI * Physician Tax ID * Physician PTAN Add Remove Procedure Site of Service Location Hospital/Facility Name * Hospital/Facility Address * Hospital/Facility Address Hospital/Facility Address Hospital/Facility Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State ZIP Code ZIP Code Hospital/Facility Phone * Hospital/Facility Fax * Hospital/Facility NPI * Hospital/Facility Tax ID * Add Remove As part of the Magnus Medical SAINT Reimbursement Hotline program, I authorize Argenta Advisors Inc, and its successor PRIA Healthcare Management LLC, including third-party contractors, on behalf of Magnus medical, 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 patient(s). Please note that your confidential information and your patient’s PHI will not be shared with Magnus Medical. * I agree Physician (or authorized person) Signature: * signature keyboard Clear Submit If you are human, leave this field blank. PROGRAM SUPPORT: MONDAY–FRIDAY 8:30AM–5:00PM EST PHONE: 844-339-8551 FAX: 844-339-8552 EMAIL: saintreimbursement@priahealthcare.com
