Focal One HIFU Reimbursement Support Hotline Provider Intake Form Provider Enrollment - Focal One Treating Center (Facility) Information Hospital/Center Name * Tax ID * NPI * Street Address * Street Address Street Address Street Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State ZIP Code ZIP Code Physician Information Practice/Group Name * Physician Name * Physician Specialty Practice/Group Tax ID # * Practice/Group NPI # * Practice/Group PTAN (Medicare) # Individual Physician NPI # * Phone * Fax * Street Address * Street Address Street Address Street Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State ZIP Code ZIP Code Add Remove Contact Information Office Contact Name * Office Contact Name First First Last Last Phone (if different than above) Email * Billing Contact Name * Billing Contact Name First First Last Last Billing Contact Phone (if different than above) Add Remove As part of the Focal One Support program, I authorize Argenta Advisors Inc, and its successor PRIA Healthcare Management LLC, including third-party contractors, on behalf of EDAP TMS to act as my designated agent and submit the information on this form to the insurer of the named patient, including through electronic payer portals and third-party platforms, for the purposes of reimbursement or appeals support. * I agree Physician (or authorized person) Signature: * signature keyboard Clear Date Submit If you are human, leave this field blank. PROGRAM SUPPORT: MONDAY–FRIDAY 8:30AM–6:00PM EST PHONE: 844-339-8152 FAX: 844-339-8153 EMAIL: HIFUReimbursement@argentaadvisors.com
