Recor Medical Recor Patient Access Program New Office Registration Form Provider Enrollment - Recor Portal User Information User Contact Name * User Contact Name First First Last Last User Contact Email * User Contact Phone * Add Remove Physicians Office Name * Physicians Office Phone * Physicians Office Fax * Physicians Office Address * Physicians Office Address Physicians Office Address Physicians Office Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Physicians Office NPI * Physicians Office Tax ID * Physician Information Physician Name * Physician NPI * Physician Tax ID * Individual Physician PTAN * Add Remove 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 Recor Medical 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: 860-999-9117 FAX: 860-782-2093 EMAIL: recormedical@priahealthcare.com
