AIM HIGHer Patient Access Program

Provider Registration Form

Provider Enrollment - AIM HIGHer Clinical Trial
Practice Address
City
State/Province
Zip/Postal
Country
Additional Location Address (1)
City
State/Province
Zip/Postal
Country
Facility Address
City
State/Province
Zip/Postal
Country
Facility Address (2)
City
State/Province
Zip/Postal
Country
Time (EST)
:
Time (EST)
:

PROGRAM SUPPORT:

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