RedDress ActiGraft ActiGraft Coverage Support Program New Office Enrollment Form REQUIRED: Click here to complete a BAA with your enrollment Provider Enrollment - RedDress 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/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal 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/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Facility Phone * Facility Fax * Facility NPI * Facility Tax ID * Add Remove ActiGraft Sales Representative Name * Date: Onboarding Call Availability (Option 1) Date: Onboarding Call Availability (Option 2) Time EST (Option 1) 121234567891011 : 0030 AMPM Time EST (Option 2) 121234567891011 : 0030 AMPM If you are human, leave this field blank. Submit PROGRAM SUPPORT: MONDAY–FRIDAY 8:30AM–5:00PM EST PHONE: 860-740-0343 FAX: 860-407-0352 EMAIL: actigraft@priahealthcare.com
