Patient Direct Appeal Program

Click here to sign the PRIA Patient Consent Form electronically

To initiate the appeal process, please complete this form in its entirety.  Once we receive your form, we will send you a secure email to submit your documents.

Focal One- Patient Direct

Patient Information

Patient Name
Patient Name
First Name
Last Name
Phone Type
If cell number was provided, do you consent to receiving text messages from DocuSign to obtain an electronic signature on any additional forms that may be required to submit your appeal?
Patient Address
Patient Address
City
State
Zip
If we need to contact you about your appeal, what is your preferred method of contact? *

Insurance Information

Is this your primary or secondary insurance?
Add Additional Insurance Remove

PROGRAM SUPPORT:

MONDAY–FRIDAY 8:30AM–6:00PM EST
PHONE: 844-339-8152  FAX: 844-339-8153
EMAIL: focalone@priahealthcare.com