BD BD Reimbursement Support Program New Office Enrollment Form REQUIRED: Click here to complete a BAA with your enrollment Provider Enrollment - BD 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 Facility Coordinator Contact Information User Contact Name * User Contact Name First First Last Last User Contact Email * User Contact Phone * User Contact Fax * Add Remove Provider Information (if applicable) Provider Name * Provider NPI * Provider Tax ID * Provider PTAN Add Remove BD 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: 860-733-0952 FAX: 860-801-8954 EMAIL: bdreimbursement@priahealthcare.com
