AIM HIGHer Patient Access Program - Provider Enrollment - PRIA Enrollment

AIM HIGHer Patient Access Program

Provider Registration Form

Provider Enrollment - AIM HIGHer Clinical Trial

Practice Name *

Practice Phone Number *

Practice Fax Number *

Practice Address *

Practice Address

Practice Address

Practice Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

Practice Tax ID *

Practice NPI *

Admin Contact Name (First and Last) *

Admin Contact Email *

Admin Contact Phone *

Impulse Sales Representative Name *

Physician Name (1) *

Physician NPI (1) *

Physician Tax ID (1) *

Physician PTAN (1) *

Physician Name (2)

Physician NPI (2)

Physician Tax ID (2)

Physician PTAN (2)

Additional Location (1)

Additional Location Address (1)

Additional Location Address (1)

Additional Location Address (1)

Additional Location Address (1)

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

Phone (1)

Tax ID (1)

NPI (1)

Facility Name *

Facility Address *

Facility Address

Facility Address

Facility Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

Facility Phone *

Facility Tax ID *

Facility NPI *

Facility Name (2)

Facility Address (2)

Facility Address (2)

Facility Address (2)

Facility Address (2)

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

Facility Phone (2)

Facility Tax ID (2)

Facility NPI (2)

Date: Onboarding Call Availability (Option 1)

Time (EST)

Date: Onboarding Call Availability (Option 2)

Time (EST)

PROGRAM SUPPORT:

MONDAY–FRIDAY 8:30AM–5:00PM EST
PHONE: (860) 900-0729 FAX: (860) 407-0359
EMAIL: AIMHIGHER@PRIAHEALTHCARE.COM