PRIAX

 

PRIAX Patient Access Program

New Office Enrollment Form

Provider Enrollment - PRIAX

Portal User Information

User Contact Name
User Contact Name
First
Last

Practice Information

Practice Address
Practice Address
City
State/Province
Zip/Postal

Physician Information

Facility Information

Facility Address
Facility Address
City
State/Province
Zip/Postal
Time EST (Option 1)
Time EST (Option 2)

 

 

PROGRAM SUPPORT:

MONDAY–FRIDAY 8:30AM–5:00PM EST
PHONE: (XXX) XXX-XXXX  FAX: (XXX) XXX-XXXX
EMAIL: XXX@priahealthcare.com