Laminate Medical - PRIA Enrollment

VasQ Reimbursement Support Program

New Office Enrollment Form

REQUIRED: Click here to complete a Business Associate Agreement (BAA) with your enrollment

Provider Enrollment - Laminate

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
State

ZIP Code
ZIP Code

Practice Phone

Practice Fax

Practice NPI

Practice Tax ID

Physician Information

Physician Name

Physician NPI

Physician Tax ID

Physician PTAN

Add Remove

Facility Information

Facility Name

Facility Address

Facility Address

Facility Address

Facility Address

City
City

State
State

ZIP Code
ZIP Code

Facility Phone

Facility Fax

Facility NPI

Facility Tax ID

Add 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)

Time EST (Option 2)

Time CST (Option 1)

Time CST (Option 2)

Time MST (Option 1)

Time MST (Option 2)

Time PST (Option 1)

Time PST (Option 2)

Laminate Medical Sales 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

Physician (or authorized person) Signature:

Clear

If you are human, leave this field blank.

PROGRAM SUPPORT:

MONDAY–FRIDAY 8:30AM–5:00PM EST
PHONE: 860-374-2647 FAX: 860-734-4791
EMAIL: VasQ@priahealthcare.com