Curonix Connect Patient Access Program

Provider Registration

Click HERE To Complete a BAA With Your New Enrollment

Provider Enrollment - Curonix

Provider Enrollment - Curonix

Prior Authorization / Appeal Coordinator Contact Information:

Contact Name *

Contact Name

First Name

First Name

Last Name

Last Name

Contact Email *

Contact Phone *

Add Remove

Practice Information

Practice Name *

Practice Phone *

Practice Fax *

Practice Office Address *

Practice Office Address

Practice Office Address

Practice Office Address

City

City

State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

State/Province

Zip/Postal

Zip/Postal

Practice Office Tax ID (TIN) *

Practice Office NPI *

Physician Information

Physician Name *

Physician Tax ID *

Physician NPI *

Physician PTAN (Medicare Provider Number) *

Add Remove

Facility Information: Trial Facilities

Facility Name *

Facility Address *

Facility Address

Facility Address

Facility Address

City

City

State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

State/Province

Zip/Postal

Zip/Postal

Facility Phone Number *

Facility Fax Number *

Facility Tax ID *

Facility NPI *

Add Remove

Facility for Perm Procedure: Perm Facilities

Facility Name *

Facility Address *

Facility Address

Facility Address

Facility Address

City

City

State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

State/Province

Zip/Postal

Zip/Postal

Facility Phone Number *

Facility Fax Number *

Facility Tax ID *

Facility NPI *

Add Remove

Curonix Sales Representative Name *

Date: Onboarding Call Availability (Option 1)

Date: Onboarding Call Availability (Option 2)

Time

121234567891011 : 0030 AMPM

Time

121234567891011 : 0030 AMPM

Point of Contact for BAA:

Name:

Email:

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PROGRAM SUPPORT:

MONDAY–FRIDAY 8:30AM–5:00PM EST
PHONE: (860) 900-0741 FAX: (860) 516.1541
EMAIL: curonixconnect@priahealthcare.com